Skip to content
Home
COVID-19 Vaccine and HAE
HAE Canada Cafe Portal
About Us
Meet the Team
Our Values
Our Vision, Mission & Goals
Our Strategic Plan: 2019 – 2024
Our Global Responsibility
What is HAE?
Causes and Types of HAE
HAE Symptoms
Diagnosing HAE
HAE Attack Triggers
HAE and Children
Frequently Asked Questions
Living with HAE
Living with HAE
Work & School Life
Pregnancy
Travel
Patient Stories
Approved HAE Treatments in Canada
New HAE Treatments on the Horizon
Clinical trials in Canada
Treatment Guidelines & HAE Specialists in Canada
Join Us
Child & Youth Program
Resources
Latest News & Events
Newsletters
Upcoming Events
Past Events
HAE in the News
Posters and Abstracts & Patient Submissions
Posters & Abstracts
HAE Canada Patient Submissions
Contact Us
Facebook
Twitter
Instagram
LinkedIn
Adult Associate Application
morten
2023-02-10T01:02:28-06:00
Adult Associate Application
Please complete this form only if applicant has permanent residency or refugee status
"
*
" indicates required fields
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
Choose Province
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
D.O.B
*
MM slash DD slash YYYY
Which of the following more accurately describes you
*
Female
Male
Non-binary
I prefer not to say
Allow me to type
Please describe yourself
*
Email
*
Home Phone
Cell Phone
Are you a: (please check ALL that apply)
*
HAE Patient
HAE Family Member
Permanent Resident
Refugee status
Other
HAE Type
*
Type 1 or 2
Normal C1 (formally Type 3)
Acquired Angioedema
Treating HAE Physician:
*
Names of family members with HAE:
*
You have selected "Other", please describe your connection to HAE:
*
Do you have any volunteer or work experience (e.g. law, finance, research, health care, public relations, marketing, board service) that you would be willing and able to share with HAE Canada as a volunteer?
*
No
Yes
Please describe your volunteer work experience:
*
Email consent
I give my express consent for HAE Canada to contact me by e-mail.
Consent for Members
I consent to becoming a member of HAE Canada and to have my name added to the mailing lists of HAE Canada. I further consent to receiving information or documents electronically. I understand that my name will be used in a manner consistent with the privacy policies of the organization as required by law. My personal information will be used to create a membership list for the purposes of sending newsletters, educational information, announcements of events, and volunteer/fund-raising appeals as well as to respond to requests for service. I understand that the information provided on the membership form will be held in confidence and that HAE Canada will not use or disclose my personally identifiable information for the purposes other than those for which it was collected except with the express consent of the individual or a person duly authorized to act on that individual's behalf. I acknowledge and accept that, as part of HAE Canada's patient advocacy role, aspects of individual HAE cases (including my own) may be discussed with my physician and other healthcare professionals for purposes of advocating on my behalf. HAE Canada will not disclose personal information about individual HAE cases (including my own) to anyone else, for any other purpose, without my authorization, or as required by law. If the personal information held by HAE Canada about me is incorrect, the organization will amend my records upon my request. A copy of the HAE Canada Privacy policy is available upon request to office@haecanada.org. I confirm I am not working for or with a pharmaceutical or insurance or other company that is providing or may provide services or products to HAE patients. By submitting this form, I consent to the collection, use and disclosure of my personal information as described above. As an associate of HAE Canada, I am not able to hold a Board position or vote at any meetings of HAE Canada. I verify that the information on this form is correct and understand that I can withdraw my consent at any time.
I have read the Consent for Members
*
I have read the Consent for Members
Comments
This field is for validation purposes and should be left unchanged.
Δ
Page load link
Go to Top