More Than Walking - Peer Mentor Sign-up
More Than Walking's Peer Mentor Interviews & Demonstrations - 2019

As described on www.MoreThanWalking.com, More Than Walking Incorporated is a non-profit that aims to document the experiences and independent living techniques of diverse individuals affected by spinal cord injury (SCI) in order to provide SCI rehabilitation centers and patients positive examples and connections to local peer mentors. All videos are being produced by Jonathan Sigworth, Co-Executive Director, More Than Walking Incorporated, 333 State St. Apt. 205, Bridgeport, CT 06604.

This form gives More Than Walking Incorporated's staff permission to contact you, share your contact information with partnered non-profit organizations engaged in peer mentoring, and to produce interviews and demonstration videos with material you submit to More Than Walking Incorporated.

Interview questions: https://www.morethanwalking.com/uploads/1/2/1/9/121925125/181128.interview_questions.pdf
Email address *
Biographical & Contact Information
First Name *
Your answer
Last Name *
Your answer
Type of Disability / Specific SCI Level *
Your answer
SCI Type
Description of Function and Sensation
Your answer
Approximate Date of Injury / Disability *
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Phone Number (xxx) xxx-xxxx *
Your answer
Street Address *
Your answer
City *
Your answer
State / Province *
Your answer
Postal Code *
Your answer
Country *
Your answer
Community Network
What is the best way to contact you? *
Mentor Certification by:
Your answer
Hospitals affiliations, where you have been treated for your disability:
Your answer
Non-profit affiliations, advocacy groups you are part of:
Your answer
Business affiliations, where you work / have worked:
Your answer
Academic affiliations, past or current schools
Your answer
Facebook Name
Your answer
Twitter Handle
Your answer
Instagram Handle
Your answer
WeChat ID
Your answer
Whatsapp Number
Your answer
Personal Website
Your answer
Personal Appearance Release
Participant Name will Appear in Published Content as *
Your answer
Possible Video Call Method *
Required
Skype ID
Your answer
Read and Sign Waiver
I, The Participant, hereby authorize Producer to record and edit into the Program and related materials my name, likeness, image, voice and participation in and performance on film, tape or otherwise for use in the above Program or parts thereof (the “Recordings”). I agree that the Program may be edited and otherwise altered at the sole discretion of the Producer and used in whole or in part for any and all broadcasting, non-broadcasting, audio/visual, and/or exhibition purposes in any manner or media, in perpetuity, throughout the world.

Producer may use and authorize others to use all or parts of the Recordings. Producer, its successors and assigns shall own all right, title and interest, including copyright, in and to the Program, including the Recordings, to be used and disposed of without limitation as Producer shall in its sole discretion determine.

Producer may publish or distribute my Mentor Affiliations and social media channels on www.MoreThanWalking.com and any More Than Walking affiliated YouTube channels or other social media platforms for the purpose of this project.
I am over 18 or the legal guardian of the participant above and I accept the terms of the waiver. *
Required
Type Your Full Name to Sign *
Your answer
Birthdate *
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A copy of your responses will be emailed to the address you provided.
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