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Heart-to-Heart Support Request
Request Type
*
Your Name
*
Organization Name (if applicable)
Email
*
Phone
*
Title/Role
*
Mailing Address
Street
*
City
*
Province/Territory
*
Postal Code
*
Request Details
Number of hearts requested
*
Please enter a number above:
Small request
(1-15 hearts) or
Large request
(50-100 hearts). If requesting over 100 hearts, please submit this form for multiple times.
How do you plan to distribute and use the hearts in your school/organization?
*
Please describe your distribution approach and intended use. For example: Will a counselor distribute them to students in need? Will they be part of a specific mental health initiative? Are they for students experiencing chronic absenteeism? Will you be establishing a peer support team to manage distribution? The more details you can provide, the better we can understand the impact of our Heart-to-Heart campaign.
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
Submit
