Survey - Peer Support Network Sign-Up Form

1.

Contact Information


*	First Name: Required
*	Last Name: Required
*	Email: Required
*	Street 1: Required
	Street 2:
*	City: Required
*	Province / State: Required
*	Postal / ZIP Code: Required
*	Phone Number: Required
	Yes, I give permission to the CLF to contact me.
	Yes, I would like to receive postal mail from Canadian Liver Foundation

*2.

Question - Required - Name of the liver disease(s) affecting you.

(Maximum response 255 chars, approx. 5 rows of text)

*3.

Question - Required - What you are hoping to achieve by signing up?

Share my experience with someone in need, to help them cope.

Be connected with someone that has experienced what I'm going through.

Other (Please briefly explain using the empty box below).

4.

Question - Not Required - Other

(Maximum response 255 chars, approx. 5 rows of text)

*5.

Question - Required - Preferred Language

English

French

Chinese