Peer Support Program

1. First Name *

Last Name *

2. Email (will also be used as the username)

No Email

3. Date of Birth * --

4. Primary Phone Number *

5. Second Number

6. Province: Are you in Ontario? *

If not in Ontario, find an association outside Ontario here >>

7. Address *

8. City or Town *

9. Postal Code *

10. Association *

Based on your location select the closest association near you

11. Gender *

If other, please specify:

12. Preferred language *

If other, please specify:

13. I am a: *

14. If you are both person with an injury and a Caregiver, you must select one for this program:

15. If you are a Caregiver, what is your relationship to the person with the concussion or brain injury?

If other, please specify:

16. Emergency Contact Name

17. Contact Relationship

18. Emergency Contact Phone Number

19. Contact Secondary Phone Number

20. What is your preferred Method of Communication *
(Choose all that apply)

Phone Email Other

If other, please specify:

21. How do you prefer to connect during your match? *

Phone Email Other

If other, please specify:

22. Preferred day for Contacting *
(Check all that apply)

23. Preferred Time for Contacting *

Morning Afternoon Evening

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