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Thank you so much for your interest in the Guelph Wellington Ontario Health Team.

We appreciate you taking the time to fill out this short form. Please answer the following questions and a member of our team will connect back with you within two weeks with more information about how you can get involved. If you have any questions, concerns or would like to connect in a different way please email askus@guelphwellingtonoht.com

Thank you for your interest and we look forward to connecting with you!
1.Where did you hear about the GW OHT?
2.Where do you live?
3.Full name:
4.Which age category do you fit into?
5.I would like to be contacted by:
6.If possible, please provide your email address:
7.If you would like to be contacted by phone, please provide your phone number.
8.OPTIONAL.  We are asking this question in order to help us understand if we are reaching diverse populations with our engagement efforts. 

Do you identify as being a part of an equity-deserving group?

Some examples include but are not limited to:  2SLGBTQIA+, Indigenous, Black, Mixed race, People of colour, Immigrants, Refugees, Living with a physical and/or mental disability, Religious and spiritual groups (Mennonite, Sikh, Muslim etc.), Working class or earning below living wage, Living in rural communities, Lack of adequate housing or houselessness, Lack of food security, Lived experience of intersectional oppression.