Request a quilt

IMPORTANT 
It is the policy of Victoria’s Quilts Canada to provide only one quilt per person suffering from cancer. The recipient’s name will be checked in our database and, should a duplication be found, we will not process the request. If you do not hear from us, you can assume that a quilt will be sent by our National Office or one of our Branches across Canada.

To request a quilt for someone with cancer, please fill out and submit the form below.

Your request will be placed on our recipients list and, as soon as a quilt becomes available, it will be sent out.

Please be aware that the usual wait time for a quilt to be delivered is several weeks. While you are waiting, please advise the recipient that you have requested a quilt for her or him, to prevent the parcel from being returned to us.

Form to request a quilt

Items with stars are required.

RECIPIENT

*First name:      *Last name:  
*Sex:   Female   Male
Name of parents (if recipient is a child):     Age (if a child):  
Address
*Street:


*City:  
*Prov./Terr.:      *Postal code:   (e.g. K2G 5Y7)
*Telephone:   (e.g. 613-843-9212)  Cell phone:  
*Language preferred for card:   English   French

REQUESTOR

*First name:      *Last name:  
Address
*Street:


*City:      *Prov./Terr.:  
*Postal code:   (e.g. K2G 5Y7)   *Telephone:   (e.g. 613-843-9212)
*E-mail:  

DELIVERY INFORMATION (required if different from recipient's)

First name:        Last name:  
Address
Street:


City:  
Prov./Terr.:      Postal code:   (e.g. K2G 5Y7)
Telephone:   (e.g. 613-843-9212)  

SPECIAL INSTRUCTIONS

Message to be included on enclosed card (optional); maximum 10 words

Comments (i.e. colour preferences, urgency, etc.).
Note: We try to satisfy your colour preferences, but this is not always possible.
In such cases, we send out an alternate quilt rather than delay filling the request.

       

Before clicking the "Submit" button, you must check the "I'm not a robot" box to prove you are a person and enable the request to go through. Please also check to make sure that all required fields have been filled in and that your email address is correct.

Once you have submitted the form, a new web page will pop up to confirm that we have received your request. You will not receive an email message.

If you do not see the web page confirming your request, please:

Thanks for stopping by!

Updated: February 1, 2017