Survey

OneCall - Peer Support Program

1. Contact Information

*

Name:

 

 

   

 

*

 

*

City/Province/Postal:

 

    

*

 

*

Date of Birth:

 

 


 

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.

 

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:

4.

5.

 

Client Services Database Permission

*6.


*7.


 

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.


*9.


   Please leave this field empty