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* Mandatory fields
Salutation
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*First name - Prénom
*Last name - Nom de famille
*Primary Email/Courriel
Email Type - Type d'e-mail
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Alternate Email Address - Adresse e-mail de rechange
Should your address become inactive.
Si votre adresse devient inactive.
 

Phone Numbers/Numéro de téléphone

Mobile Phone - Téléphone mobile
Home Phone - Téléphone fixe Maison
Work Phone - Téléphone de travail
Prefer contact on - Privilégiez le contact sur
Clear selection
 

Physical Address - Adresse physique

Organization - Organisme
If you are joining due to your work position. Si vous nous rejoignez en raison de votre poste de travail.
Title/Role in Organization - Titre/Rôle dans l'organisation
Optional Address Line - Ligne d'adresse facultative
Please use for Building Name etc.Veuillez utiliser pour le nom du bâtiment, etc
Street Address - Adresse de rue
Start with Unit number if applicable. For Apartment 2 on 123 Street it would show as 2-123 Street
Commencez par le numéro d'unité, le cas échéant. Pour l'appartement 2 de la 123e rue, il s'affichera sous la forme 2-123e rue
City - Ville
Postal Code/Zip -Code postal / ZIP
 

Other Information (optional) - Autres informations (facultatif)

Preferred Language/langue préférée
Other Languages Spoken / Autres langues parlées
Birthday - date de naissance
...
Please enter your date of birth.
Veuillez entrer votre date de naissance.
Year of Birth (4 numbers ex 2022)
Month of Birth
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Gender you identify as - Sexe auquel vous vous identifiez
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Avatar
If you chose, you may upload a profile photo or avatar. These may be used on the Members Only Access pages.
Si vous le souhaitez, vous pouvez télécharger une photo de profil ou un avatar. Ceux-ci peuvent être utilisés sur les pages d'accès réservées
Please describe yourself - Veuillez vous décrire
Please indicate the Rare Disorder Veuillez indiquer le trouble rare :
Classification of your Rare
English- Choose the Emails you will receive
Français - Choisissez les e-mails que vous souhaitez recevoir
 

Additional Members Membres supplémentaires

Additional family members not directly affected by a Rare Disorder
If these individuals are affected by PKU or other Allied Disorder we suggest you create a "Bundle/Family" plan and provide them with their own record. This is a handy spot to record non affected children or additional parents/guardians.
Autres membres de la famille non directement touchés par une maladie rare
Si ces personnes sont atteintes de PCU ou d'un autre trouble apparenté, nous vous suggérons de créer un plan "Forfait/Famille" et de leur fournir leur propre dossier. C'est un endroit pratique pour enregistrer les enfants non affectés.
 

OPTIONAL: Social Media Links - FACULTATIF : Liens vers les réseaux sociaux

Facebook
Enter your Facebook link
(For your privacy we have locked this information. If you wish to share it with the members you will need to unlock it in your profile)
Instagram
Enter your Instagram Name
(For your privacy we have locked this information. If you wish to share it with the members you will need to unlock it in your profile)
SnapChap
Enter your SnapChat ID
(For your privacy we have locked this information. If you wish to share it with the members you will need to unlock it in your profile)
Gaming ID -ID de jeu
Twitter
Enter your Twitter Name
(For your privacy we have locked this information. If you wish to share it with the members you will need to unlock it in your profile)
WWW. website - site Internet
LinkedIn
Enter your LinkedIn Profile
(For your privacy we have locked this information. If you wish to share it with the members you will need to unlock it in your profile)
YouTube Link - Lien YouTube
 

Clinic Data

Clinic Attended - Clinique actuelle
Who is your metabolic doctor? Qui est votre médecin métabolique ?
Any other clinical individuals? D'autres professionnels de santé clinique?
Physicians Email - Courriel des médecins
Clinics street address - Adresse postale de la clinique
Clinic City - Ville de la clinique
Clinic Province - Province de la clinique
Clinic Postal Code - Code postal de la clinique
Clinics Phone Number - Numéro de téléphone de la clinique
 

Paperwork

Signed Covid Release for 2022 Event
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Subscription source1
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DTC Starter

Need help from CanPKU for DTC? Besoin d'aide de CanPKU pour CIHR?
Date Requested Help - Date de la demande d'assistance
...
Physician to complete documents - Médecin pour compléter les documents
Who is applying for the Disability Tax Credit? Qui demande le crédit d'impôt pour personnes handicap
Has CanPKU+ Assigned Primary Support Person
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Who is the CanPKU+ Primary Support Person
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It appears we are waiting on the applicant for an update or an action. Sent a request on
...
Does your clinic know you will be applying for DTC - Est-ce que votre clinique est au courant
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Clinic Discussion - Discussions avec la clinique
Name of person with Rare Disorder Nom de la personne atteinte d'un trouble rare
Is the beneficiary 18 years or older? Le bénéficiaire a-t-il 18 ans ou plus?
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If yes, Do you have the power of attorney over this applicant? Avez-vous le pouvoir de représenter
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First time the applicant is applying? Est-ce la première fois que vous demandez le DTC
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Previous attempt approved? La tentative précédente a-t-elle été approuvée ?
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Is it time to renew? Est-il temps de renouveler ?
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Was a previous application started but not yet completed or approved?
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Please tell us about the previous application
Approval for collection and sharing of DTC information.
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This information will be shared with a trusted volunteer in order to assist your application. We may utilize other information such as your diagnosis and date of birth to offer programming and services related specifically to you.
Is/Was the membership current at time of request for help?
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Has CanPKU+ Sent the spreadsheet survey to applicant
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Waiting on Spreadsheet survey? En attente du tableau de bord du sondage sur le tableur
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Date the Spreadsheet Survey was received.
...
 

Information ONLY if applicant applied without CanPKU+ help in the past.

Stages of application at time of requesting help
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If applicable, What date was the application sent in?
...
If applicable, What date was the denial received?
...
If applicable, What date was the Notice of Objection sent in?
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If applicable, What is the Court Date?
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If applicable, What date was the approval received?
...
If Applicable, What date is the renewal due?
...
This will help us remind you of your upcoming renewal.
Do you have documents from the government regarding your application?
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Are you willing to share these documents with us?
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DTC Documents RECEIVED from the Government
You can upload up to 20 files. Each file should be less than 20 MB.
You can upload digital content here (like a file or photo of the document.) It will allow for multiple uploads. You can upload up to 20 files. Each file should be less than 20 MB.
 
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260 Adelaide Street East, #180
Toronto, ON, M5A 1N1, Canada
Toll Free: 1-877-226-7581 (1-877-CANPKU1)
Email: info@canpku.org


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