MLA and ME

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MLA and ME

Thank you for your interest in consideration for a role as a participant partner in our My MLA and ME campaign. This short survey should take about 5 minutes.

Individuals selected for this initiative must be able to commit to building a relationship with a sitting MLA (ideally in your riding but you may be assigned to another), participating in video zoom meetings, telephone calls and supporting your conversations with exchange of materials and files as provided by the Society.

This current campaign is about ME. Participants may have co-conditions, but must have ME.

Please provide your first and last name. *

What is your email address? *

What riding do you live in? (If you don't know your riding, please state your town/city) *

What is the name of the MLA in your riding? *

Have you engaged with your MLA before (about ME or another topic)? *

Yes

3. Please provide information on the following: *

I am a person with ME

I am a caregiver to a person with ME

I am a family member of a person with ME (but they don't require care from me)

I am a friend of someone with ME

I/my person with ME has been diagnosed and meets the Canadian Consensus Criteria (CCC) for ME *

yes

unsure

Other:

I/my person with ME would be considered : *

mild

moderate

severe

very severe

I am able to commit to building a relationship with my designated MLA, holding phone conversations, zoom meetings (or similar set ups) and am equipped with a working computer, headsets/microphones and stable internet connection. *

Yes, I agree

I'm unsure if I can commit

Other:

I am a current member of the ME/FM Society of BC? *

Yes

Unsure

Please provide a contact phone number *

By submitting this form, your information will be collected and reviewed by the Society committee leading this project. Your information collected here will not be made public or advertised. We are seeking a range of MLA connections across the province. Therefore, not all survey participants will be contacted to join us. Thank you for putting your name forward to possibly support this effort. *

I have read and understood the above statement

I am unclear about my participation in the survey

Required

Submit

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