Adult Membership Application - HAE Canada

D.O.B*

Please describe yourself*

Email*

Home Phone

Cell Phone

Treating HAE Physician*

Names of family members with HAE:*

You have selected "Healthcare Provider", please list area of practice/expertise:*

You have selected "Other", please describe your connection to HAE:*

Please describe your volunteer work experience:*

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. I verify that the information on this form is correct and understand that I can withdraw my consent at any time.

Name

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