Mentor Application
Notification
Thank you for your interest in volunteering to mentor teens with cancer from across Canada through Teen Connector. The Childhood Cancer Foundation - Candlelighters Canada defines a mentor as a cancer survivor who has been through a childhood cancer experience and is post treatment. As a mentor your personal experience as a cancer survivor is invaluable to teens who may be feeling overwhelmed, vulnerable and alone. Teens will look to you for support, advice, and motivation as they progress through their journey. Of course each person's experience is unique and any medical questions should be re-directed to an oncologist or doctor.
Kindly respond to the following questions to let us know about yourself. We really appreciate your interest and will get back to you soon. Please note that several fields filled out below will become part of your permanent public profile and you will be unable to make changes upon acceptance without permission from Teen Connector. Also be advised that a valid, up to date Police Check will be required in order to further participate in training, and mentoring. Please note that there are only limited number of positions.
If you are not selected as a mentor at this time, but you are a teenager, we encourage you to register and become a member of Teen Connector as your active participation will be beneficial to you and other users.
Basic Information
Okay, let's get started.
First Name*:
Last Name*:
Email (Username)*:
Password*:
Password confirm*:
Gender:
Male
Female
Birth Date*:
01
02
03
04
05
06
07
08
09
10
11
12
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
Home Town:
Cancer Experiences
Your answers to the information below tells us about your cancer experience and should you be selected as a mentor, it will help us link you with teens who will look to you for support.
Type of Cancer:
Leukemia
Lymphoma
Sarcoma
Cancer of the Central Nervous System
Brain Cancer
Cancer of the Kidney (Renal)
Other Type of Cancer
Sub Categories:
Acute Lymphoblastic Leukemia (ALL)
Acute Myeloid Leukemia (AML)
Other
Specific Initial Diagnosis:
Age at Initial Diagnosis:
What was the main hospital you were treated in?
What was the name of your primary oncologist?
Please check off all that you experienced during your cancer journey.
PROCEDURES:________________________________________________________________________
Biopsy
Bone Marrow Aspirate
Bone Marrow Transplant
Lumbar Puncture
Stem/Bone Marrow Harvest
Dialysis
Tube Insertion (e.g Catheter,Chest,NG)
Tests/Scans (e.g., CAT, MRI, ECG)
HOSPITAL STAYS:____________________________________________________________________
Critical/Intensive Care Unit Admission
Clinic Visits
Infection
Inpatient Admission
Isolation
Emergency/Ambulance/Unusual Occurrence
Neutropenia (Low Blood Count)
SURGERY:____________________________________________________________________________
Central Line/Port/Pic Line Insertion
Surgery
TREATMENT:_________________________________________________________________________
Morphine Infusion
Port Access
Radiation
Course of Chemotherapy
Intramuscular Injection
TPN (Total Parenteral Nutrition)
Antibiotics
Transfusion (Low Blood Count)
Relapse
NPO (nothing by mouth before procedure or surgery)
PHYSICAL CHANGES:_________________________________________________________________
Hair Loss/Thinning
Weight
Appetite
Nausea
Facial Hair
Swelling
Mouth Sores
Due to Surgery (eg.scars,limps,loss of mobility)
Pain
Devices (eg.walking,hearing,artificial limbs)
EMOTIONAL CHANGES:________________________________________________________________
Mood Changes due to drugs
Mood Changes due to stress
Changes in relationships (parents, siblings, friends)
SCHOOL EXPERIENCE:________________________________________________________________
In Hospital Instruction
Able to Attend School
Home Schooling
Tutoring
Correspondence or Online Courses
TREATMENT COMPLETION:____________________________________________________________
How long did your treatment last?
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Year(s)
Month(s)
Based on the items you checked off above what were some of the challenges you faced in each topic?
Procedures
Hospital Stays
Surgery
Treatment
Physical Changes
Emotional Changes
School Experience
Why do you want to be a mentor to teens experiencing cancer?
Personal Information
Tell us a little about your interests and what you do during your spare time.
What are you doing now? (work, school, spare time activities):
Favourite Things To Do
Favourite Music
Favourite TV Shows
Favourite Movies
Favourite Books
Favourite Quotations
About Me Tidbits
Who do you admire?
Contact Information
We may need to contact you other than by email.
Mobile Phone:
Home Phone:
Address:
City / Town:
Province:
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Québec
Saskatchewan
Yukon
Postal Code:
Terms of Use
Welcome to the Teen Connector website! Effective Date: September 1, 2009 The Childhood Cancer Foundation – Candlelighters Canada knows how important it is to receive emotional support during a health challenge. At Teen Connector, we provide a platform that will allow you, your family and friends to stay in touch during and after a life changing health event. When you register for Teen Connector, you will be able to post journal updates about your progress, upload and share photos, receive support from mentors and both seek and provide advice on discussion boards. Teen Connector is an informational resource for you, and we hope a valuable one, but we are not providing medical advice, diagnosis or treatment. Decisions about the best lifestyle choices and medical treatments should be made in consultation with your personal health care providers, whom you choose based on your own needs. As with any website providing a social networking platform, as well as tools and information, there are rules about what you can and can’t do, and what we will and won't do. Those are captured below in our Terms and Conditions. Please read them carefully because we want to be sure you understand and accept them before you use or register for Teen Connector. The following terms constitute an agreement between you and the Childhood Cancer Foundation – Candlelighters Canada ("we" or "us"), the operator of Teen Connector (the “Site”). This agreement ("Terms and Conditions") governs your use of the Site as a Member or Mentor (as defined below). BY USING THE SERVICE, BY REGISTERING WITH US, YOU SIGNIFY THAT YOU AGREE TO THESE TERMS AND CONDITIONS, including that you agree to transact with us electronically and that you consent to the information practices disclosed in our Privacy Policy. Please note that we offer the Site "AS IS" and without warranties. 1. About the Site The Site contains a range of information and tools relating to health, wellness and communication. You can register and find a mentor or apply to become a mentor. As a registrant you can keep family and friends updated during your journey with cancer. You can learn through our resource center, connect through the mentor process, discussion forums and blogs. In order to create your page or apply to be a mentor on Teen Connector you must register. Review our Privacy Policy and Community Guidelines for additional information on how we do business. 2. Registration Teens must register to become part of Teen Connector. You can register by visiting the Teen Connector homepage and clicking on the “Register Now” button. Once registered, you can create your own page or find a mentor and invite your friends and family to access your page. As a Visitor, you may access only the part of Teen Connector to which you have access. Before you make a post in any part of the Site, you will be required to create a display name. You may not use a display name that is vulgar, attempts to impersonate another person, or violates the rights of others. 3. Your Personal Information The Teen Connector Privacy Policy explains the information practices that applies to the pages you are managing or visiting, as well as the personal information we have about you. You consent to the transfer of the personal information to and within Canada for processing and storage by us. 4. Your Responsibilities During registration you will provide information about yourself and create a password. These are your credentials for accessing Services that are only available to members ("Credentials"). You agree that we, and vendors acting on our behalf, may use your Credentials to authenticate you on the Site. You are responsible for all uses of the Site using your Credentials, including use by others to whom you have given your Credentials. You are responsible for keeping your password confidential and for notifying us if your password has been hacked or stolen. If you discover that someone is using your password or account without your consent, or you discover any other breach of security, you agree to notify us immediately at tcteam@childhoodcancer.ca. You may use the Site and Services for lawful, non-commercial purposes only. We mechanically screen for objectionable information transmitted or shared by members to monitor the screened content and, if considered objectionable in our sole discretion, to remove the information and/or remove the page from our system at any time without notice. When creating or maintaining a page or posting to the Site, you must comply with the Community Guidelines. You must always comply with these Terms and Conditions including the Section entitled Restrictions on Use. 5. Creating and Maintaining Teen Connector Profiles Teen Connector Profiles can be created and managed by a Teen Patient or by a Mentor. When creating or updating the Profiles, be respectful to your healthcare facility and team and do not post any photographs of hospital staff, physicians or other patients without their express written consent. Posts should not contain defamatory or libelous remarks about your healthcare facility or members of the healthcare team. If you have concerns about the care you are receiving, a patient relations representative is available at all healthcare facilities to provide personal assistance. 6. Postings and Feedback The Site allows Members to make postings (e.g., messages, blogs, stories, updates and images) in your Profile area of the Site. You can restrict your postings on your Teen Connector Profile. Please be thoughtful with your Postings, and avoid offending others or infringing their rights. You may not post Postings that violate these Terms and Conditions or the Community Guidelines and we reserve the right to block your ability to post and/or to access the Site and Services if you do. You continue to own the copyright in your Postings but, by submitting Postings to Public areas of the Site, you grant us and our affiliates the right to use, copy, display, perform, distribute (through multiple tiers of distributors), adapt, translate, edit, and promote your Postings in any medium now known or later developed and any manner we choose, and to use your display name or, in the case of public areas of Teen Connector website, your first name to attribute your postings to you if we so choose. While some discussion forums and blogs are monitored for topicality, we have no obligation to prescreen Postings, and are not responsible for their content. We encourage you to notify us of inappropriate or illegal content and we reserve the right to remove Postings for any reason. We are not, however, responsible for any failure or delay in removing Postings. Keep in mind that the Postings of others are simply their opinions and you should not rely on them. In addition to Postings, you may submit feedback to us. We welcome your feedback regarding our Site and Services. You agree that we may use in any manner and without limitation all comments, suggestions, complaints and other feedback you provide relating to the Site or Services, and that we will own all intellectual property that we create based upon or incorporating your feedback. 7. Your Use of Content All of the editorial content (“Content”) available on the Site is owned by us, our suppliers, and our contributors, and is protected by international treaties, copyright and trademark, laws and may have security components that protect digital information. We give you permission to use the Content for personal, non-commercial purposes only. You may also print, download, and store articles and other information for your own convenience, but you may not distribute, republish, sell, mine, exploit, frame or scrape any of the Content, or exploit the Content for commercial gain. Email us at tcteam@childhoodcancer.ca for information on how you can request limited permission to reproduce certain Content from the Site. 8. Links to Other Sites The Site may include links to other websites, including links that may be provided as automated search results. Some of these sites may contain materials that are objectionable, unlawful, or inaccurate. These links are provided for your convenience only and do not mean that we endorse these sites or the products and services they provide. You acknowledge and agree that we are not responsible or liable for the content or accuracy of these other sites. Information and links for the purposes of making donations to funds that are established to provide support for members or us are permissible. Members are advised to donate at their own risk. Teen Connector is not responsible for donation requests or payment links posted by Members and expressly disclaims any liability related to donation related links on any Teen Connector Profiles. 9. Linking To the Site You generally do not need to obtain permission from us to put a text link on your site that links back to the Teen Connector website. We reserve the right, however, to revoke permission to the link at any time in our sole discretion. If we revoke such consent, you agree to immediately remove and disable any and all of your links to the Site. In the absence of a written agreement with us specifying how you may link to the site, use the following guidelines for adding one or more links to the Site from your website: The link must be a text-only link that clearly includes the phrase “Teen Connector" The link must "point" to a page on www.childhoodcancerfoundation/teenconnector.ca 10. Changes to the Site and Services We may from time to time modify the Site, add new Services, substitute a new Service for an existing Service, or discontinue an existing Service. Information about new Services will be included on the Site, and, unless otherwise indicated, the use of new Services will be governed by these Terms and Conditions. 11. Additional Terms Certain Services on the Site may have additional terms (such as policies, guidelines, and rules) that will further govern your use of that particular Service and supplement these Terms and Conditions. If you choose to register for or access any such Service, you will be presented with any relevant additional terms and conditions at that time. By using those Services, you agree to comply with such additional guidelines and rules. 12. Special Note for Parents This site is a general audience site and not designed or intended to attract children under 12 years of age. We do not collect personal information from any person we actually know is under 12 years of age. Parents and guardians permitting children to use the Site, should be aware that any information voluntarily given by children in chat sessions, email exchanges or message boards may be viewed by third parties. If you have any questions regarding children’s privacy, please send an email to tcteam@childhoodcancer.ca 13. Changes to These Terms and Conditions We may change these Terms and Conditions at any time, as we deem appropriate. If we make changes that we believe will have a material impact on your use of the Site, we will let you know by sending you an email if we have a current email address for you, and by noting on the Site that the Terms and Conditions have been updated. If you disagree with the changes to these Terms and Conditions, discontinue your use of the Site, or if you have registered as a member, cancel your registration. Your ongoing use of the Site after the changes take effect signifies your agreement to the new terms. We encourage you to review the Terms and Conditions regularly. 14. Restrictions on use To help ensure that everyone’s experience at Teen Connector is a positive one, we have certain rules of conduct which we expect you to follow. You agree you will: • not post any material that might infringe the intellectual property, privacy, publicity or other proprietary rights of anyone else; • not use contact information provided by our users, or harvest information about our users, for the purpose of sending, or to facilitate the sending, of unsolicited bulk communications such as SPAM or SPIM • not interfere with or disrupt the Site’s services or systems; • not transmit or post any materials that contain viruses, Trojan horses or other harmful programs; • not attempt to gain unauthorized access to the Site or any Teen Connector Profiles; • not provide false information on your registration form, impersonate any person or otherwise mislead anyone on the Site; • not use any robot, spider, scraper or other automated means to access the Site in a manner that sends more request messages to our servers in a given period of time than a person can reasonably produce in the same period. If you are public search engine, however, you may use spiders to copy materials on the Public areas of the Site solely as necessary to create publicly available searchable indices of the Public materials. Public Search Engines may not create caches or archives of such materials. We may take any legal and technical remedies to prevent the violation of this provision and to enforce these Terms and Conditions. 15. International Use The Site and Services, including the information provided on the Site, are designed for and intended for users in Canada. We make no representation that the Site or Services are applicable to, appropriate for, or available to users in locations outside Canada. 16. We Make No Warranties YOU AGREE THAT YOUR USE OF THE SITE SHALL BE AT YOUR SOLE RISK. WE PROVIDE THE SITE AND THE SERVICES “AS IS”. TO THE FULLEST EXTENT PERMITTED BY LAW, THE CHILDHOOD CANCER FOUNDATION, JAAN TECHNOLOGIES AND THEIR AFFILATED COMPANIES, THEIR OFFICERS, DIRECTORS, EMPLOYEES, SPONSORS AND AGENTS (FOR THE PURPOSES OF THIS PARAGRAPH, THE NEXT TWO PARAGRAPHS, AND THE PARAGRAPH ON DISPUTE RESOLUTION, COLLECTIVELY, “WE”, “US” OR “OUR”) DISCLAIM ALL WARRANTIES, EXPRESS OR IMPLIED, IN CONNECTION WITH THE SITE INCLUDING THE IMPLIED WARRANTIES OF MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NONINFRINGEMENT, SECURITY AND COURSE OF DEALING. WE MAKE NO WARRANTIES OR REPRESENTATIONS ABOUT THE ACCURACY OR COMPLETENESS OF THIS SITE'S CONTENT OR THE CONTENT OF ANY SITES LINKED TO THIS SITE AND ASSUME NO LIABILITY OR RESPONSIBILITY FOR ANY (I) ERRORS, MISTAKES, OR INACCURACIES OF CONTENT, (II) PERSONAL INJURY OR PROPERTY DAMAGE, OF ANY NATURE WHATSOEVER, RESULTING FROM YOUR ACCESS TO AND USE OF THE SITE, (III) ANY UNAUTHORIZED ACCESS TO OR USE OF OUR SECURE SERVERS AND/OR ANY AND ALL PERSONAL INFORMATION AND/OR FINANCIAL INFORMATION STORED THEREIN, (IV) ANY INTERRUPTION IN THE SERVICES OR THE SITE, (IV) ANY BUGS, VIRUSES, TROJAN HORSES, OR OTHER HARMFUL PROGRAMS TRANSMITTED THROUGH THE SITE; AND/OR (V) ANY ERRORS OR OMISSIONS IN ANY CONTENT OR FOR ANY LOSS OR DAMAGE OF ANY KIND INCURRED AS A RESULT OF THE USE OF ANY CONTENT ON THE SITE. WE DO NOT WARRANT, ENDORSE, GUARANTEE, OR ASSUME RESPONSIBILITY FOR ANY PRODUCT OR SERVICE ADVERTISED OR OFFERED OR ADVERTISED BY A THIRD PARTY THROUGH THE SITE. You may have additional consumer rights under your local laws that this contract cannot change. You use the Site and the Services at your own risk. 17. We Do Not Provide Medical Advice THIS SITE AND THE SERVICES OFFER INFORMATION ABOUT HEALTH AND EMOTIONAL SUPPORT AND ARE DESIGNED FOR EDUCATIONAL PURPOSES ONLY. YOU SHOULD NOT RELY ON THIS INFORMATION AS A SUBSTITUTE FOR, NOR DO THEY REPLACE, PROFESSIONAL MEDICAL ADVICE, DIAGNOSIS, OR TREATMENT. IF YOU HAVE ANY CONCERNS OR QUESTIONS ABOUT YOUR HEALTH, YOU SHOULD ALWAYS CONSULT WITH A PHYSICIAN OR OTHER HEALTH-CARE PROFESSIONAL. DO NOT DISREGARD, AVOID OR DELAY OBTAINING MEDICAL OR HEALTH RELATED ADVICE FROM YOUR HEALTH-CARE PROFESSIONAL BECAUSE OF SOMETHING YOU MAY HAVE READ ON THIS SITE. THE USE OF ANY INFORMATION PROVIDED ON THIS SITE IS SOLELY AT YOUR OWN RISK. NOTHING STATED OR POSTED ON THIS SITE OR AVAILABLE THROUGH ANY SERVICES ARE INTENDED TO BE, AND MUST NOT BE TAKEN TO BE, THE PRACTICE OF MEDICAL OR COUNSELING CARE. FOR PURPOSES OF THIS AGREEMENT, THE PRACTICE OF MEDICINE AND COUNSELING INCLUDES, WITHOUT LIMITATION, PSYCHIATRY, PSYCHOLOGY, PSYCHOTHERAPY, OR PROVIDING HEALTH CARE TREATMENT, INSTRUCTIONS, DIAGNOSIS, PROGNOSIS OR ADVICE. DEVELOPMENTS IN MEDICAL RESEARCH MAY IMPACT THE HEALTH, FITNESS AND NUTRITIONAL INFORMATION THAT APPEARS HERE. NO ASSURANCE CAN BE GIVEN THAT THE INFORMATION CONTAINED IN THIS SITE WILL ALWAYS INCLUDE THE MOST RECENT FINDINGS OR DEVELOPMENTS WITH RESPECT TO THE PARTICULAR MATERIAL. Your access or use of this Site and the Services does not create in any way a physician/patient, confidential, or privileged relationship, or any other relationship that would give rise to any duties on our part or the part of our suppliers. We do not recommend or endorse any specific tests, physicians, procedures, opinions, or other information that may appear on the Site. If you rely on any of the information provided by this Site, its employees, or its guests or visitors, you do so solely at your own risk. 18. Limitation of Liability We will not be liable, whether in contract, tort, strict liability or otherwise, for any indirect, punitive, special, consequential or incidental damages (including without limitation lost profits or lost opportunity) arising out of or in connection with the use of this Site, or a linked site, including any delay or inability to use the Site or linked site, even if We were made aware of the possibility of such damages. In no event WILL we be liable for the procurement of substitute services. THE CUMULATIVE AMOUNT OF OUR LIABILITY TO YOU, no matter the nature of your legal or equitable claim, WILL NOT EXCEED $100. These limitations on liability includes, but are not limited to, the transmission of any viruses which may infect your equipment, failure of equipment or communication lines, unauthorized access, theft, operator errors, strikes or other labor problems or any force majeure. Although We will use commercially reasonable efforts to address any problems or concerns regarding the Site or the Services, if you continue to be dissatisfied with this Site or services or with any of these Terms and Conditions, your only remedy is to discontinue using Teen Connector and terminate your registration. 19. Termination We may terminate and/or suspend your registration immediately, without notice, if there has been a violation of these Terms and Conditions or other policies and terms posted on the Services by someone using your Credentials. We may also cancel or suspend your registration or your Teen Connector Profile, for any other reason, including inactivity for an extended period, but will attempt to notify you in advance of such cancellation or suspension. We may terminate the Site, the Services, or any Service, at any time, without notice. Your right to use the Services will end once your registration is canceled or terminated, and any data you have stored on such a Service may be unavailable later, unless we are required to retain it by law. You may terminate your registration by contacting Teen Connector customer support at tcteam@childhoodcancer.ca. 20. Indemnification Upon a request by us, you agree to defend, indemnify, and hold harmless us, our employees, contractors, officers, directors, agents, parent, other affiliated companies, and suppliers, from all liabilities, claims, and expenses, including attorney's fees, that arise from your use or misuse of the Site and the Services or any breach by you of these Terms and Conditions. We reserve the right to assume control of the defense of any third party claim that is subject to indemnification by you, in which event you will cooperate with us in asserting any available defenses. 21. Electronic Contracting and Notices Your affirmative act of using this Site and/or registering for the Site or Services constitutes your electronic signature to these Terms and Conditions and your consent to enter into agreements with us electronically. You also agree that we may send to you in electronic form any privacy or other notices, disclosures, reports, documents, communications or other records regarding the Services (collectively, “Notices”). We can send you electronic Notices (1) to the email address that you provided to us during registration, or (2) by posting the Notice on the applicable Service or otherwise through the Site. The delivery of any Notice from us is effective when sent by us, regardless of whether you read the Notice when you receive it or whether you actually receive the delivery. You can withdraw your consent to receive Notices electronically by canceling or discontinuing your use of the applicable Service. In order to receive Notices electronically, you must have a personal computer with a modem connected to a communications source (telephone, wireless or broadband), and a Windows-based operating system with an Internet browser or a Macintosh-based operating system with an Internet browser. You will need a printer attached to your personal computer to print any Notices. You can retrieve an electronic copy and a printable version of this contract by clicking on the “Terms and Conditions” link on any web page that hosts any of the Services. All contracts completed electronically will be deemed for all legal purposes to be in writing and legally enforceable as a signed writing. 22. Entire Agreement This contract and any supplemental terms, policies, rules and guidelines posted on the Site and the Services constitute the entire agreement between you and us and supersede all previous written or oral agreements. If any part of these Terms and Conditions is held invalid or unenforceable, that portion shall be construed in a manner consistent with applicable law to reflect, as nearly as possible, the original intentions of the parties, and the remaining portions shall remain in full force and effect.
I agree with the terms
Security Code
To help us fight spam, please enter what you see in the box below.
Please Note: This site has been designed for you but we'd appreciate your feedback. Don't hesitate to send us your ideas and suggestions:
tcteam@childhoodcancer.ca
.
Home
-
Log In
-
Register
About Us
Help
Privacy
Terms and Conditions
Recover Password