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Heart-to-Heart Support Request
Request Type
*
Your Name
*
Organization Name (if applicable)
Email
*
Phone
*
Mailing Address
Street
*
City
*
Province/Territory
*
Postal Code
*
Request Details
Number of hearts requested
*
Please enter a number above: Small order (1-15 hearts) or Large order (50-100 hearts). If requesting over 100 hearts, please submit this form for multiple times.
Special requests or considerations (optional)
Shipping Cost Reimbursement
If requesting 50-100 hearts, please provide payment information for the $20 Canada Post shipping fee reimbursement:
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Acknowledgment
By submitting this form, I understand that:
YMHC will process my request based on availability of hearts
Hearts are sent at no cost, except for shipping costs, as part of YMHC's mental health advocacy
Information provided will be kept confidential and used only for processing this request
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