Support Group Intake Form

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Page 1

Dear Fellow LDS Community Members,

This support group is designed to:

Share your personal experiences with LDS
Unpack your difficulties with this condition; and
Find comfort within OUR community

To best serve your needs, please take approximately 5-10 minutes to respond to the following questions.

Thank you in advance and we look forward to meeting you!

Primary Information

Full Name (and the name you go by if it differs):

Email Address:

Age:

Please select the sessions you plan to attend (select all dates that apply):

Monday, September 18, 2023 @ 6:00 PM Eastern TimeMonday, October 16, 2023 @ 6:00 PM Eastern TimeMonday, November 20,, 2023 @ 6:00 PM Eastern TimeMonday, December 18, 2023 @ 6:00 PM Eastern Time

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Confidentiality and Data

All participants are required to:

read the Loeys-Dietz Syndrome Foundation Canada’s Privacy Policy (Find the policy here:

https://loeysdietzcanada.org/wp-content/uploads/2022/09/LDSFC-Privacy-Policy_02-09-2022.pdf

Sign the Consent Form (complete the additional form here: https://www.tfaforms.com/4973013)
Sign the Confidentiality Form (complete the additional form here: https://www.tfaforms.com/5074436)

Note: The additional forms are not needed to reserve your spot in any upcoming sessions but are required before the start of your first session.

Thank you for taking the time to fill out this survey. It's important to remember that you are not alone. Within this support group, you will find others who share the daily struggles and triumphs of living with LDS.

Please continue to the Signature Page to complete your registration.

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Contact Information