Virtual Support Group Registration

Online Form for Virtual Support Group

Thank you for your interest in joining our virtual support groups. Please fill out the registration form below and the Community Service Lead for your area will reach out to you with a Zoom invitation.

* are mandatory fields that are required

I am:

A person diagnosed with a blood cancer

In remission or living with chronic blood cancer

A caregiver

A family member

A healthcare provider

Other…

First Name

Last Name

Date of Birth

Phone Number

City

Province

Postal code

Pronouns

Disease Information

Please select the diagnosis

Month and Year of Diagnosis

Please provide any additional comments or information you feel the LLSC staff member should know about before they contact you.