Submit a request – Staywell Charity

How can we help you?

Your email address

Phone Number

Subject

I am a (Patient, Social Worker, Caregiver)

Patient Name

Patient Email

Suite Type

Check-In Date

Check-Out Date

Parking Required?

Postal Code

Please use the format A1A 1A1. Postal codes help StayWell identify potential funding opportunities for you.

Hospital of Treatment

Illness Type (e.g. Cancer, Heart, Transplant, Lungs, Brain, etc.)

This will help StayWell identify potential funding opportunities for you.

Story(optional)

How did you hear about us?

Notes

Please enter the details of your request. A member of our support staff will respond as soon as possible.

I have read and agree to the Waiver and Release:

https://storage.googleapis.com/staywell/StayWell%20Waive%20and%20Release.pdf

Consent Form

I hereby authorize StayWell to collect and use the personal information provided in this request form, and any other personal information that I provide in connection with this request, to confirm my eligibility to receive services from StayWell and to provide me with services. I authorize StayWell to disclose my personal information to temporary housing providers for the purposes of confirming the availability of temporary housing that matches my needs and contacting me about such temporary housing. If I provide StayWell with personal information about another individual to use and disclose for these purposes, I acknowledge that I have their consent to do so.

Email Updates(optional)

I would like to receive email updates about StayWell’s services. I understand that I can withdraw my consent at any time.

Attachments(optional)

Add file or drop files here