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Program Form

The first step to participating in one of our programs is to fill out a Program Form. 

Once the form is submitted, we will connect with you within a week to discuss details.

If you require help, more information or would like to talk with someone, please call our main number at 905-984-8766 or email info@hospiceniagara.ca.

Hospice Niagara is committed to policies that affirm and protect the right to care and treatment which is accessible, inclusive, secure and respectful to all.
Learn more about our policies.

First Name:

Last Name:

Home Phone:

Cell Phone:

Email:

City:

Please check all program that are of interest to you:

Is there any additional information that may be helpful for us to know about the reason(s) you would like support?

If you have an urgent medical concern or are experiencing a medical emergency, please contact your community nurse or call 911. If you are experiencing an urgent mental health concern or crisis, please contact COAST at 1-866-550-5205.

Please contact us at 905-984-8766 to ensure your accessibility needs are accommodated through this process. Information received relating to accommodation measures will be addressed confidentially.