High School Outreach Advocacy Interest Form

Advocate application for outreach activities

Please complete the questions below if you are interested in volunteering for advocacy activities within the University of Toronto Transplant Institute. You must be either a transplant recipient, living donor, or donor family member.

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* 1. Please complete all fields below.

Name

Address

Address 2

City/Town

Province

Postal Code

Primary Email Address

Phone Number - Cellular preferred

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* 2. Are you a:

Transplant recipient (received an organ)

Living organ donor

Donor family member

Family member of a recipient

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* 3. Please indicate which organ you either received/donated/family member donated

Heart

Lung

Kidney

Liver

Pancreas

More information (multiple transplants, etc)

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* 4. What led to the need for your transplant - please list disease/condition

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* 5. Have you had previous experience in public speaking?

Yes

If so, please specify organization groups/meetings/etc,

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* 6. How comfortable are you sharing your transplant story?

Very easy

Easy

Neither easy nor difficult

Difficult

Very difficult

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* 7. What areas are you available to travel to speak? Please select all that apply.

Peel region (Mississauga, Brampton areas)

West End (Etobicoke)

Toronto area (Downtown TO, Thornhill, East York)

East End (Scarborough)

Other (please specify)

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* 8. How flexible are you during the week (Monday - Friday between 8:30am - 3:30pm)?

Pretty flexible

Quite flexible given certain considerations (list below)

Not flexible

Please list if there are specic days you are not available or periods of time which you would be unavailable (if known).

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* 9. Would you be interested in other outreach/education activities?

Extremely interested

Very interested

Somewhat interested

Not so interested

Not at all interested

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* 10. Do you have a current year Vulnerable Police Sector Check on file?

Yes

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* 11. Based on your current mailing address, what area do you reside?

York

Durham

Toronto

Peel