Survey - OneCall - Peer Support Program

1.

Contact Information

*

Name:

First Name Required	Last Name Required

Email:

*

Address 1: Required

Address 2:

*

City/Province/Postal:

City Required	Province Required	Postal Required

*

Phone Number: Required

Gender:

*

Date of Birth: Required

Date of Birth:

Yes, I would like to receive email from the MS Society of Canada.

I would like to receive postal mail from the MS Society of Canada.

The following information will be used to arrange a single call with a volunteer as soon as possible. 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.

Question - Required - Please describe the question, topic, or theme which you are most interested in discussing during your call.

Please provide information on your MS history or if you are caregiver, the MS history of the person you support

*3.

Question - Required - Type of MS/Allied Disease:

	Clinically Isolated Syndrome
	Relapsing-remitting MS
	Secondary-progressive MS
	Primary-progressive MS
	Allied Disease
	Other

4.

Question - Not Required - Please describe current symptoms (if relevant to your question).

5.

Question - Not Required - Please provide any other information that you think is relevant to your question.

Client Services Database Permission

*6.

Question - Required - Do we have your permission to enter your application information into our service database? This is necessary for participation in the program in order to connect you with a volunteer. The internal database is completely confidential and only accessible by MS Society staff.

*7.

Question - Required - Do we have your consent to release relevant information (ie. name, contact info) to a OneCall Peer Support Program volunteer?

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

8.

Question - Not Required - I understand that MS Society peer support volunteers are not professional counselors and cannot provide medical advice.

*9.

Question - Required - I acknowledge that I understand the intent thereof, and I hereby agree and absolve and hold harmless the Multiple Sclerosis Society of Canada, corporate sponsors, co-operating organizations and any other parties connected with this program in any way, singly or collectively, from and against any blame and liability for any injury, misadventure, harm, loss, inconvenience, or damage hereby suffered or sustained as a result of participation in one or more of the events above or any activities associated therewith. I hereby consent to and permit emergency treatment in the event of injury or illness.