Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
Contact Form
Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
bowl least residing
Have you been told by your doctor that you have an autoimmune rheumatic disease (ARD); any type of ARD, including rheumatoid arthritis, juvenile onset arthritis, systemic lupus erythematosus, psoriatic arthritis, ankylosing sponsylitis, Sjögren's syndrome, systemic sclerosis, and arthritis from inflammatory bowl disease or Crohn’s (scleroderma).
*
No
Yes
Do you currently live in Canada ?
*
No
Yes
Your province / territory that you are currently residing ?
*
Please select your Province / Territory
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Saskatchewan
Quebec
Yukon
Are you at least 18 years old?
*
No
Yes
Do you currently have at least 1 child between the age of 0 and 12
*
No
Yes
Are your comfortable reading and writing in English or French?
*
No
Yes
In terms of your parenting identity, do you identify as a:
*
Mother
Father
Name
*
First
Last
Phone
*
Our team will call this phone number to confirm that you are eligible for the study. If we cannot reach you, we cannot enroll you.
Best days to call you:
*
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Best time of day to call you:
*
Mornings
Afternoons
Evenings
Email
*
Slide to select correct answer: 20+24=
Selected Value:
0
You will
NOT
receive the survey automatically by completing this form. Someone from our team will reach out to you, by phone, to confirm your eligibility and explain the next steps.
Submit
