Bethell Hospice Resident/Community Client Consent - For Bethell Hospice Foundation

Bethell Hospice Foundation exists to raise funds to ensure the ongoing operation of Bethell Hospice in our community. Unlike many other local charities, Bethell Hospice depends on the generosity of donors simply to remain in operation. Government funding through the Ontario Ministry of Health only covers staffing costs for direct medical care at Bethell Hospice. Every other cost, including items like food, medication, facility management, utilities, and community and outreach programs, are funded directly from donations. In order for Bethell Hospice Foundation to best support the programs and services provided by Bethell Hospice, it is imperative we stay connected to the community we serve.

Resident/Client Information:

Select Option

Hospice Residence Client

Community Client

Preferred Pronoun:

HE

SHE

THEY

ZE

Other

Name

LEGAL First Name:

Middle Name

Last Name:

Preferred Name/known Nickname(s):

Address:

Phone (Home):

(Cell):

Email:

Substitute Decision Maker Information:

Relation To Client:

Preferred Pronoun:

HE

SHE

THEY

ZE

Other

Name

First Name:

Last Name:

Address:

Phone (Home):

(Cell):

Email:

Please review and acknowledge the following applicable statements:

I understand the programs and services provided by Bethell Hospice are free of charge due in part to the generosity of donors and community partners.

I understand that completion of this form is required as part of my consent for service with Bethell Hospice Residence or Bethell Hospice Community program.

I understand that the Foundation provides "In Memory" and "In Honour” notifications to the identified recipients.

Consent:

I CONSENT to having my contact information and that of my Substitute Decision Maker shared with Bethell Hospice Foundation for the purpose of receiving details about Foundation activities and be invited to participate in fundraising initiatives as appropriate.

I CONSENT for my name OR name of resident OR community client to be included in the annual special ‘In Memory’ section of the Bethell Hospice Foundation’s published newsletter if applicable.

I DO NOT CONSENT for my contact information to be shared with Bethell Hospice Foundation for the purpose of participating in and receiving details about Foundation fundraising initiatives.

I DO NOT CONSENT for my name OR name of resident OR community client to be included in the annual special ‘In Memory’ section of the Bethell Hospice Foundation’s published newsletter, if applicable.

Notifications:

In addition to my Substitute Decision Maker, I would like the following person(s) to be notified should a donation be made in my honour/memory. *

Name

First Name:

Last Name:

Address:

Phone (Home):

(Cell):

Email:

Contact Me:

I would like the Foundation to reach out to discuss questions I have about making a donation, memorial giving or general inquiries about Bethell Hospice Foundation.

Resident/Client

Substitute Decision Maker

Print Name:

Signature:

Dated:

Please forward a copy of this completed form to the following email address for my records:

Email Address

Messages sent via the internet can be intercepted. If you are concerned about providing your personal information by email or website form submission, please contact us directly at 905-838-3534 to arrange for an alternate method of communication

For more information, please refer to our Bethell Hospice Privacy Statement.

Resident/Community Client Consent – For Bethell Hospice Foundation

Resident/Client Information:

Substitute Decision Maker Information:

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