Share Your Moment

As you might know, the Alberta Cancer Foundation focuses on creating more moments for Albertans facing cancer, and we are currently doing a campaign around capturing those kinds of moments in photos and selfies, of patients, survivors, family members and friends. These pictures can be of anything that is important to you, or represents a special moment in your life, and will be used to help build our ambassador program and might appear in a variety of Alberta Cancer Foundation communications materials like social media or impact reports.

Fill out the form below to share your moment:

Name*
First Last
Address*
Street Address Address Line 2 City Province Postal Code
Email*
Photo or Selfie Description*
Date of Photo or Selfie*
MM slash DD slash YYYY
Photo (can be a selfie!)*
Drop files here or

Accepted file types: jpg, png, gif, pdf, tiff, Max. file size: 10 MB.
Images provided must be a minimum of 2MB in size.
CAPTCHA
Privacy Considerations*
I agree to the privacy considerations.
I consent to my own personal information (including written content about myself as included in this submission form, in whole or in part) and/or my own individually identifying health information, being:

• used by the Alberta Cancer Foundation; and,
• disclosed by the Alberta Cancer Foundation to general public in the form of written (electronic and/or print) content for the purposes of:
- • The Alberta Cancer Foundation’s' website (accessible nationally and internationally); and/or
- • media release materials; and/or
- • publications; and/or
- • promotions; and/or
- • presentations; and/or
- • displays; and/or
- • social media; and/or
- • other public communications mediums.
I acknowledge that I am aware that by submitting this form, I am permitting the Alberta Cancer Foundation to use and/or disclose my personal information (including written content about myself as included in this submission form, in whole or in part) and/or individually identifying health information, and am aware of the risks and benefits of consenting to the use and /or disclosure of the same. I understand that I may revoke this consent at any time by giving written notice to: acfonline@albertacancer.ca.

I release and discharge the Alberta Cancer Foundation and those for whom each is responsible at law, from all responsibility and liability for the content of the above mentioned, and the specific uses to which they may be applied. I declare that this release and discharge shall be binding upon my heirs, executors, administrators and assigns.

I acknowledge that, while the Alberta Cancer Foundation may contact me to learn more about my story, stories may be shared as submitted in one of the Alberta Cancer Foundation’s publications. Also, I acknowledge that not every story submitted will be included in an Alberta Cancer Foundation publication.

* By agreeing to the consent form you confirm each individual represented in the photo gives consent to using their photo.

I agree to the Privacy Considerations