Child & Youth Associate Application

HAEC Associate Form (0-18 years old, child, youth, teen)

Child & Youth HAE Canada Associate Application and Agreement Form Only complete this form if under the age of 18. If older than 18, please complete the member form.
  • Date Format: YYYY slash MM slash DD
  • Consent for HAE Canada Associate on Behalf of a Minor (18 years and under)

    I consent to permit the aforementioned to become an associate of HAE Canada within the Child and Youth Group and to have their name added to the mailing lists of HAE Canada. I further consent to receiving information or documents electronically. I understand that their name will be used in a manner consistent with the privacy policies of the organization as required by law. Their personal information will be used to create a Child and Youth group list for the purpose 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 this form will be held in confidence and that HAE Canada will not use or disclose my child’s, nor my own, 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 child's) may be discussed with their physician and other healthcare professionals for purposes of advocating on my behalf for the minor in my care. HAE Canada will not disclose personal information about individual HAE cases (including my child’s or 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 the minor in my care 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 the personal information of the minor in my care, and any of my own, as described above. I verify that the information on this form is correct and understand that I can withdraw the minor's consent at any time.