Visitor Application Form

Please fill out the online form below.

Once you have completed this form, you will access three additional pages at the right column.  A hard copy of the three forms needs to be filled out and the originals received via Canada Post by March 1, 2009.

Part I - Client Information

Please note that the "Applicant" is the person who has received or is currently receiving cancer treatment. Please fill out their information. 

Applicant's First Name  
Applicant's Last Name  
Guardian's First Name  
Guardian's Last Name  

If you are not the applicant, or the applicant is not 18 years of age, please state your relationship to the applicant and authority to represent and sign on behalf of (i.e.: parent, etc.):

   
How did you hear about the program?  
   
email   
   
Telephone - daytime   
Telephone - evenings   
Mobile phone   
fax   
   
Street address   
City   
Province   
Postal code   

A maximum 6 cottage guests, including applicant are invited to each cottage. Please include their names and relationship to the applicant. For those under the age of 18, we will require ages.

Name:   Age:   Relationship:  
Name:   Age:   Relationship:  
Name:   Age:   Relationship:  
Name:   Age:   Relationship:  
Name:   Age:   Relationship:  
           

Active treatment completion date:  THIS FIELD IS MANDATORY

Preferred week away in this month:   THIS FIELD IS MANDATORY


Preferred areas to visit 
Please note that the dates and locations are used as a guideline and are not guaranteed. We will offer placements into cottages at the times they are offered to us by the owners


By clicking in the checkbox I am agreeing to the terms and conditions described to me on the Cottage Dreams website. I understand that all information will be kept confidential and that the final decision for acceptance and inclusion lays with the Board of Directors and/or the Matching Committee of Cottage Dreams Recovery Initiative Inc.


I will provide a physician representing Cottage Dreams permission to access all necessary medical information as it relates to the assessment of my application as a candidate for the Cottage Dreams program.



You're not quite finished! Once you have clicked “submit” you will be instructed to download and print forms that must be signed and returned to Cottage Dreams by the program deadline. These forms are also available on the top right side of this page.

Copyright Cottage Dreams 2004.  All Rights Reserved