1:1 PEER SUPPORT PROGRAM VOLUNTEER APPLICATION

Fields marked with an asterisk * are mandatory. All other fields are optional.

Are you 18 years of age or older?

YesNo

Contact Information

First Name	Last Name
Pronouns	Self-describe
Gender	Self-describe
Email	Phone
Street Address	City
Province	Postal Code
Country

About You

What connection, if any, do you have to MS?

Specify Connection

Date of Birth

MM/DD/YYYY

In what language(s) are you fluent?

EnglishFrenchOther

Other Language(s)

Areas of interest (check all that apply)

Administration (ex. data entry, research and compile information)Advocacy (ex. meet with elected officials, help people with MS access funding)Community events (ex. help at a food station, assist with event check in)Event planning (ex. organizing committee for MS Walk or MS Bike)Group opportunities (ex. volunteer with your team from work)Marketing and communications (ex. creative writing, graphic design)Media (ex. print, radio, tv)Peer support (ex. lead a support group, provide one-on-one phone support)Public speaking (ex. share your story at an event, moderate an educational presentation)Represent MS Canada in your community (ex. build community partnerships, promote MS Canada events and initiatives)Wellness (ex. facilitate a virtual wellness session)Youth / young adult opportunities (ex. community building with other young adults under 39)

Emergency Contact

First Name	Last Name
Relationship	Email
Phone

Communication Preferences (please select all that apply)

I would like to receive emails from MS Canada regarding upcoming volunteer opportunitiesI would like to receive emails from MS Canada about the organization, its impact, and other ways I can help. I can withdraw my consent at any time

Peer Support Program: Communication and Match Information

For communicating with the program coordinator, what is your preferred form of communication?

Additional Comments

For communicating with your peer, what is your preferred form of communication?

What other forms of communication work for you for providing peer support?

Do you have a phone plan that covers long distance calls?

YesNo

Please tell us why you are interested in becoming a Peer Support Volunteer with MS Canada.

What hobbies or favourite leisure activities do you enjoy (i.e., cooking, photography)?

Do you have children? If so, how many?

MS History: Please share your history of MS or, if applying to offer caregiver support, please respond based on the person you care for.

Type of MS / Allied disease

Year of diagnosis

Symptoms

Mobility

Medication (please enter N/A if this does not apply)

Treatments / Alternative therapies

Living arrangements

If other, please specify

If you are a caregiver, what is your relationship to the person with MS / allied disease (i.e., parent, spouse, sibling)

Screening: A Criminal Record Check is required to participate as a volunteer in this program.

When requested, are you willing to agree to a Criminal Record Check completed through MS Canada (at no cost to you?)

YesNo

Additional Information

Is there anything else you would like us to know?

Do you give MS Canada permission to share your name with other volunteers?

YesNo

Information shared in this application will be used to make a match. Do you give MS Canada permission to share your information with a person seeking peer support?

YesNo

Volunteer Waiver, Policies and Procedures

Code of Conduct and Ethical Behaviour Click here to read I agreeI do not agree	IT Acceptable Use Procedures Click here to read I agreeI do not agree
Privacy & Confidentiality Click here to read I agreeI do not agree	Volunteer Waiver Agreement Click here to read I agreeI do not agree
Respectful Workplace & Environment Policy Click here to read I agreeI do not agree	AODA Click here to read I agreeI do not agree

COVID Measures Support Statement
As a member of the MS Community, I acknowledge that the safety and health of the MS Community is our top priority. I support efforts to safeguard the health of people living with MS, our families and our friends by following recommended public health measures like washing my hands frequently, wearing a mask when in close proximity to others in an indoor space, and staying home if I feel sick.

I agreeI do not agree

Privacy Statement
MS Canada collects the personal information of volunteers for the purpose of communicating information to you about MS Canada and its programs, events and volunteer opportunities, and to compile anonymous statistical information. By completing this form, you acknowledge and consent to the collection and use by MS Canada of your personal information for these purposes. If you have any questions about your personal information, or MS Canada's privacy policy please contact our Privacy Officer at priv@mscanada.ca.

I agreeI do not agree

Adult applicant sign off

Name	Date
Signature Please re-type your name to complete the sign off process.

We are committed to accommodating volunteer’s needs throughout their journey with us. Please contact volunteer@mscanada.ca should you need accommodation.

reCAPTCHA helps prevent automated form spam.

The submit button will be disabled until you complete the CAPTCHA.