Self Registration Which of our services are you interested in? (Please select all that apply) Service Navigation Peer Program Family Peer Program Employment Services Last 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 InformationPlease complete either Section A or B depending on your disabilitySection A: SCIDate of Onset (DD/MM/YYYY) DD slash MM slash YYYY SCI DiagnosisPlease SelectParaplegiaQuadriplegiaInjury Level Injury TypePlease selectTraumaticNon-traumaticInjuryFallMotorized Vehicle AccidentAssaultSports & RecreationOther TraumaInjuryInfectionInflammation/DegenerationCancerHaematological or VascularCongenitalStructuralNeurologicalComplications from SurgeryOtherOther Section B: Non-SCINon-SCI DiagnosisPlease SelectALSArthritisAmputationCerebral PalsyCharcot Marie-Tooth DiseaseChronic Inflammatory Demyelinating Polyneuropathy (CIDP)Degenerative Disk DiseaseDiscitisGuillain Barre Syndrome (GBS)HemiplegiaMeningitisMultiple SclerosisMuscular DystrophyOsteoporosisPolio or Post-Polio SyndromePolyneuropathySpinal Muscular AtrophyOtherOther Additional Conditions for both SCI and Non-SCIPlease selectABIAddictionsAdditional Mental Health ConditionsArthritisBlindDeafDiabetesFibromyalgiaHard of hearingLearning DisabilityVisual ImpairmentOtherOther Please stateHow can we help?Mobility Aids Used (Select all that apply) Braces Cane Crutches Manual Wheelchair Power Wheelchair Prostheses Scooter Splint Walker 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.
