Registration: VON's Community Dialogue on Meals on Wheels

Thank you for your interest in improving the Meals on Wheels program. Please tell us about yourself.

We will use the information you provide below to contact you about VON's engagement opportunity. VON respects your privacy and will not sell, rent, or share your information with others. For more information, please read our statement of information practices.

Please do not include any personal health information belonging to yourself or any other person in your responses.

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* 1. What is your full name?

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* 2. What is your phone number?

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* 3. What is your email address?

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* 4. What city do you live in?

Mississaugua

Oakville

Etobicoke

Other (please specify)

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* 5. How do you identify your ethnic/racial background? (Select all that apply)

Black or African American or Caribbean

First Nations or Aborignial

South Asian (e.g. East Indian, Pakistani, Bangladeshi, Sri Lankan)

White or Caucasian (e.g. European)

East or South East Asian (e.g. Filipino, Korean, Japanese, Chinese)

Latin American

Middle Eastern (e.g. Iranian, Syrian)

First Nations, Metis or Indigenous

Unknown

Prefer not to say

Other (please specify)

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* 6. What is your first language?

English

French

Indigenous Language

Hindi

Urdu

Punjabi

Arabic

Pashto

Balochi

Dari

Ukrainian

Polish

Mandarin

Cantonese

Serbo-Croatian

Slovene

Macedonian

Russian

Other (please specify)

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* 7. What age range do you fall into?

Under 18

18-24

25-34

35-44

45-54

55-64

65+

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* 8. What is your current work status?

Working for pay part-time (e.g. retired part-time, homemaker part-time)

Working for pay on a casual or on-call basis

Not working, able to work

Not working, unable to work

Retired

Student (working / not working part-time)

Home maker

Other (please specify)

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* 9. Please let us know which one of the sessions would you like to attend

October 25 (Online) from 10:00 AM-11:00 PM

October 27 (In-Person) from 5:30-7:30 PM - Free meal will be served

October 29 (Online) from 10:00-11:00 PM

Other (please let us know if you would prefer to share your insights over the phone or email engagement@von.ca)

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* 10. Do you need any supports to fully participate in the engagement activity? (child care, transportation, accessibility, caregiving, technology, breaks, etc?)

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* 11. Do you have any dietary needs or preferences? Please specify.

By clicking “Submit Responses” you consent to VON collecting and using the information you have provided to contact you about participation opportunities with VON’s Client and Family Engagement Program.