Family Registration Family Member InformationLast Name First Name Pronouns Preferred Name Date of Birth (dd/mm/yyyy) DD slash MM slash YYYY Gender Male Female Other Other Primary Phone numberPrimary Phone Type Home Cell Secondary Phone numberSecondary Phone Type Home Cell Email Address Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Primary LanguageEnglishFrenchOtherTranslator NeededNoYesDisability InformationThese questions relate to the person with the SCI (Please fill out as much as possible)CompleteCompleteIncompleteSCI Level Injury TypePlease selectTraumaticNon-traumaticTraumaticFallMotorized Vehicle AccidentAssaultSports & RecreationOther TraumaNon-traumaticInfectionInflammation/DegenerationCancerHaematological or VascularCongenitalStructuralNeurologicalComplications from SurgeryOtherOther ConditionsPlease selectABIAddictionsAdditional Mental Health ConditionsArthritisBlindDeafDiabetesFibromyalgiaHard of hearingLearning DisabilityVisual ImpairmentOtherOther Mobility Aids Used (Select all that apply) Braces Cane Crutches Manual Wheelchair Power Wheelchair Prostheses Scooter Splint Walker How can we help you?Consent By checking this box and providing my e-mail and home address above, I agree to receive information from Spinal Cord Injury Ontario. We respect your privacy, and you can unsubscribe at any time.
