The Rural/Remote Caregiver Initiative Registration Form (Northern Ontario)

The Ontario Caregiver Organization (OCO) is looking for caregivers who reside in Northern Ontario to participate in a focused discussion to gather insights and feedback on the factors that play a role in determining health care access for caregivers living in rural and remote areas. The OCO is looking to deepen its understanding and elevate the diverse voices of caregivers who live outside of urban and suburban areas. This initiative will conduct an all-day in-person forum, in Thunder Bay, by bringing together caregivers from across the region. The aim of the forum is to learn more about the challenges in accessing care faced by caregivers who live in rural and remote communities. The event will happen on Thursday, October 2, 2025.

The Ontario Caregiver Organization (OCO) defines caregivers as ordinary people who provide physical and emotional support to a family member, partner, friend, or neighbour of any age, without pay. Care may be needed due to frailty, palliative care, long-term illness, long-term recovery from accident or surgery, degenerative disease, physical, cognitive, or mental conditions or disabilities.

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1. Note: While we appreciate and value all interest, we are looking for caregivers from a wide spectrum of caregiving experiences to participate in the forum, focusing on the rural experience. Spaces are limited; registration does not guarantee participation. Caregivers will be contacted with confirmation.

If you are not at the in-person event, we would still love to hear your experience. Would you be interested in participating in a survey?

Yes, add my email

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2. Please enter your contact information:

Full Name:

Address:

City/Town:

Province:

Postal Code:

Email Address:

Phone Number

Emergency Contact (Name & Number):

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3. If unable to drive, do you need assistance with travel (flight or train)?

Yes

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4. If interested in attending, but unable to, what is the reason? (this question is for data collection purposes only)

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5. Who are you caring for or who have you been caring for? (Select all that apply)

Young Child/Children (17 years of age and younger)

Adult Child/Children (18 years of age and older)

Friend(s), Neighbour(s), Colleague(s) and/or Extended family such as aunt(s), uncle(s), cousin(s)

Grandparent(s)

Parent(s)

Sibling(s)

Spouse/Partner

Prefer not to answer

Other (please specify)

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6. Which of the following health condition(s) affect the person(s) you are providing care for? (Select all that apply.)

Acquired brain injury

Addiction

Aging/old age

Alzheimer’s disease or Dementia

Arthritis (such as rheumatoid arthritis, osteoarthritis, gout)

Autoimmune disorder (such as lupus)

Back problems

Cancer

Cardiovascular disease (such as heart disease, heart attack, stroke)

Developmental disabilities (such as intellectual disability, Autism Spectrum Disorders, Down syndrome, cerebral palsy, Fetal Alcohol Spectrum Disorders, language and learning disorders)

Diabetes

Chronic pain

Genetic disorders

Kidney disease or failure

Infectious diseases (such as HIV/AIDS, Lyme Disease, Tuberculosis)

Long COVID or post-COVID conditions

Mental illness (such as anxiety, depression, PTSD, OCD, bipolar disorder, eating disorder, mania, schizophrenia or other psychosis-related disorders)

Neurological diseases (such as ALS, Parkinson’s disease, multiple sclerosis, spina bifida, cerebral palsy, epilepsy or post-polio syndrome)

Recovery from surgery

Recovery from accident or injury

Respiratory conditions [such as Asthma, chronic bronchitis, cystic fibrosis, emphysema, chronic obstructive pulmonary disease (COPD)]

Spinal cord injury

Visual, hearing, or physical disability

Don’t know

Prefer not to answer

Other (please specify)

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7. Photo and Video Consent

During the feedback sessions, there will be a photographer and videographer present to capture moments from the event. Please advise below whether you're comfortable being included.

I grant OCO and its agents, service providers, subcontractors, volunteers, and employees (“OCO Personnel”) permission to use, produce, reproduce, and distribute one or more of the following (please check all applicable boxes):

Interviews, stories, testimonials, and experiences including my full name

Photographs taken of me

Videos taken of me

Audio recordings

Confidentiality Pledge- Please Read

Privacy is of the utmost importance to the Ontario Caregiver Organization (“OCO”). To help OCO create a safe space for participants to feel comfortable and to freely share personal experiences, we require that all participants agree with this Confidentiality Pledge, before submitting the form.

What types of information should I keep confidential and private?

OCO encourages participants to share their experiences openly. By participating in this forum, a participant will often learn private details about another individual’s life and experiences as a caregiver. You may hear about the following information that you must keep confidential:

· names of group participants and names of their family and friends;

· personal health information about group participants and their care-recipients (e.g., diagnoses, their journey through the health care system, the care they provide(d), and treatments involved in care);

· experiences and stories; and

· other personal information, beliefs, feelings, and perceptions.

Often our facilitators are volunteers who will also share their own experiences with you. These experiences and details must also be kept confidential. The above is not an exhaustive list, but the general rule is what you hear or learn in the forum stays private. If you are unsure if something should be kept confidential, the answer is most likely yes! If you see another participant in public or someone you know from the forum, we kindly ask that you keep their information confidential and respect their privacy.