Survey

Extended Program - Peer Support Program

1. Contact Information

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Name:

 

 

   

 

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City/Province/Postal:

 

    

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Date of Birth:

 

 


 

The following information will be used to make a match with a volunteer who is living with MS or who is the caregiver of a someone living with MS. This information will be stored in accordance with the MS Society of Canada’s privacy policy and will not be shared beyond the coordination of this program.

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*3.
Question - Required - What is your communication preference? (check all that apply)
Please make at least 1 selection from the choices below.

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Please provide information on your MS history or the MS history of the person you support

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Question - Required - Type of MS/Allied Disease:

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*15.

16.
Question - Not Required - Current living arrangements?

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Client Services Database Permission

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Privacy Statement


The Multiple Sclerosis Society of Canada collects your personal information for the purpose of communicating information about the MS Society to you, its programs and fundraising activities. By completing this form, you acknowledge and consent to the collection and use by the MS Society of your personal information for these purposes. If you have any questions about your personal information or the MS Society's privacy policy, contact our Privacy Officer at priv@mssociety.ca.

 

Waiver

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Please fill in contact information for your emergency contact.

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   Please leave this field empty