Survey

MS Peer Support Program Peer Application

1. Contact Information

*

Nom :

 

 

   

 

*

 

*

Ville/Province ou État/code postal :

 

    

*

 

 

Date de naissance :

 

 


 

The following information will be used to make a match with a volunteer who is 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.

*2.


*3.
Question - Required - What is your communication preference? (check all that apply)
Veuillez faire au moins 1 sélection à partir des choix ci-dessous.

*4.


*5.

*6.

*7.


8.

*9.  


  Your MS History
*10.  


*11.
Question - Required - Type of MS/Allied Disease:

*12.

*13.

*14.

*15.

16.
Question - Not Required - What are your current living arrangements?

*17.

*18.

*19.

 

Client Services Database Permission

*20.


*21.


 

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

*22.


*23.


24.


  Emergency Contact Information
25.  


26.  


27.  


*28.


   Veuillez laisser ce champ vide