Health Organization Support Form

Health Organization Support Form
WELCOME!

This support form is a quick and easy way to lend your support to the creation of content that promotes the well-being of Canadians.

Health Organizations that deliver healthcare services to Canadians are mandatory partners in projects financed by TELUS Fund. They provide feedback to help the producer ensure content is accurate, unbiased, and evidence based.

Please show your support by completing this form:
1. Be sure to "SAVE" your progress at the bottom of each page.
2. Add your signature to the last page, and push "SUBMIT".
3. You will automatically receive a PDF version of the completed form.
4. An email with the completed form will also be sent to the Canadian Production company and TELUS Fund.
Get in touch at info@telusfund.ca, if you have any questions. You'll find more information about TELUS Fund on our website.
Thank you for supporting the creation of well-being content!

Your Organization
Name of your organization*
Address*

Street Address

Street Address Line 2

CityProvince / Territory

Postal Code
Phone number*
Organization website*
Enter URL address
Contact Person for this support form*

First NameLast Name
Email for Contact Person*
example@example.com
Phone Number for Contact Person*
What is the mission or purpose of your organization? *

Maximum words0/100
Please describe the professional healthcare services your organization is directly delivering to individuals in Canada affected by the well-being issue featured in the project. These services must support physical, mental, emotional, or spiritual well-being and be delivered by—or under the supervision of—regulated health professionals within your organization.*

Maximum words0/100
In which regions in Canada does your organization deliver healthcare services?*

One or more metropolitan centres, cities, or towns in Canada1 province or territory of Canada2 to 5 provinces or territories of CanadaAcross more than 5 provinces or territories of Canada
In which languages does your organization deliver these healthcare services?*

EnglishFrenchOther

Signature
The undersigned hereby releases the TELUS Fund (the Fund) and its directors, officers, members, employees, administrators, agents, and representatives from any liability for the disclosure, unauthorized use, or reproduction of any data, information or documentation submitted with this form. All risks associated with the transportation of any data, information or documentation submitted with this form are assumed by the undersigned. The undersigned authorizes the Fund to discuss and disclose any and all information submitted with this form with every entity connected (in the Fund’s opinion) with the project.

The undersigned hereby warrants that the information provided in this form is complete and accurate and that the signatory has the full authority to submit this form to the Fund. The undersigned acknowledges that the Fund has full discretion in administering its programs including, without limitation, determination of eligibility and in the application of the Fund’s program guidelines to ensure that funding is provided to those projects that meet the mandate and objectives of the Fund.

The undersigned hereby agrees that the Fund is not responsible in any way for the holding or return of any materials submitted at any time in connection with this form and the Fund retains the right to keep on file or destroy all materials submitted by the undersigned.

By applying your signature below, the Applicant(s) confirms having read the above terms, the Terms of Use and the Privacy Committment.
Signature/ Stamp- DATE*

Clear
Name of signatory*

First NameLast Name
Please provide the signatory’s title and a short description of their role at the Health Organization (e.g., Executive Director, Clinical Director, Program Manager).
Should be Empty:

	Name of platform or channel	URL to the platform or channel, if any	Total reach in Canada (subscribers, followers)	Average views or engagement
1
2
3
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Health Organization Support Form

WELCOME!

Thank you for supporting the creation of well-being content!

Health Organization

Your Organization

The Well-being Content

Signature