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Lived Experiences Advisory Council
Referral Form
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* Indicates required question
Participant Full Name
*
Your answer
Phone Number
*
Your answer
Can we leave a voice message for you?
*
Yes
No
Email Address
*
Your answer
Participant Location
*
South Stormont
North Stormont
South Glengarry
North Glengarry
South Dundas
North Dundas
City of Cornwall
Akwesasne
I identify or align with the following:
*
Person of Colour
Person with disability
Indigenous, Metis or Inuit
LGBTQ+
Youth (Up to 29)
Senior
Employed (Full or Part-time)
Single Parent
Francophone
Newcomer to Canada
None
Required
Why do you want to be a member of the Lived Experience Advisory Council?
*
Your answer
Do you have access to technology that would allow you to connect with us by video?
Yes
No
Clear selection
What kind of technology do you have access to?
*
Smart Phone
Tablet
Laptop
Desktop Computer with camera
Other:
Required
Do you have internet access?
*
Yes
No
Referring Organization
Your answer
Referring Consultant
Your answer
I [participant] authorize my referring consultant and the Social Development Council to exchange information as it relates to my potential participation on the Lived Experience Advisory Council.
*
Yes
No
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