EmailMe Form - Submit your story

Name *

First Last

Email *

Phone *

### - ### - ####

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Is this story about: *

When were you or your loved one diagnosed? *

How old were you or your loved one when you/they were diagnosed? *

What brain tumour type do you or your loved one have (if known)?

What's the grade of your/their tumour (if known)?

Low grade (1-2)

High grade (3-4)

Share a brief synopsis of your story or your loved one's story (You also have the option to share a brief video of your story instead of providing text here, as indicated in the next question.):

(Maximum 200 words)

Upload a short video of your/their story (optional):

At Brain Tumour Foundation of Canada, we strive to provide hope. What does hope mean to you? *

(Maximum 200 words)

Would you agree to have us share your story or your loved one's story online or offline (website, social media, press, radio, TV, annual report, and more)? *

Yes

No

I would like to sign up to:

BrainStorm newsletter (Monthly)

InfoCervo French newsletter (Bi-monthly)

By submitting this form, you consent to us processing your data, including any sensitive health information about you or your loved one. Your details will be stored securely in our database and will never be shared with other organizations for marketing purposes.