MS Society of Canada - Support & Services

finding a cure - enhancing quality of life

Services for you and your family

Scholarship Program

Education

Camp for Children and Teens with MS

Advocating for yourself

MS Clinics

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Multiple Sclerosis

Publications and recommended resources

MS Answers

I have MS

I may have MS

I am a caregiver of someone with MS

I am a spouse or partner of someone with MS

I am a teen with MS

I am the parent of a child with MS

I am newly diagnosed with MS

Young Persons With MS :
A network for families with a child or teen with MS

Informational Form (to be completed by parent or guardian)

Today's date:

Parent Information

Parent name(s):

Street address:

City:

Province:

Postal Code/Zip Code:

E-mail address:

Telephone numbers:

Mother (H)

Mother (W)

Father (H)

Father (W)

Child Information

Name of child:

Date of birth:

Age:

Month/year of diagnosis:

Does he/she reside at the same address as above ?

Yes

If not, his/her current address:

Child's grade in school :

List other household members:

Email Group

Please use my email above to register me for the Network Email Group so I can receive e-mails from other families living with children or teens with MS.

Yes

*Your email addreess is kept completely confidential
unless you choose to share it.

I give my permission to the manager of the FAMILY SUPPORT NETWORK to share my contact information with my local Multiple Sclerosis Society of Canada Chapter so I can learn more about local programming and opportunities.

Yes

Multiple Sclerosis Society of Canada
Toll free to reach the nearest regional office: 1 800 268-7582

To locate the MS Society office near you, please select your region:

E-mail: info@mssociety.ca
(Please provide your town and province in your e-mail)

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