Living Well APPPLICATION

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Living Well With Lung Disease Program - Application

First name*

Last name*

Multi-line address

Country/Region

Address

City

Zip / Postal code

Phone*

Email*

Age*

Under 40

40-49

50-59

60-69

70-79

80+

Prefer not to say

Lung disease*

For the purposes of research and project funding we are looking to better understand the financial status of participants households. *

Less than $30,000

$30,000 - $49,999

$50,000 - $74,999

$75,000 - $99,999

Over $100,000

Prefer not to say

I understand that as part of this project data sharing of evaluations between iMaster Health and LungNSPEI will occur. No identifying factors will be shared.

Project evaluations and data collection are a crucial part of this program. I consent to completing evaluations which may take place via email and/or phone. No identifying factors will be disclosed.

I am interested in supporting LungNSPEI in raising awareness about lung disease by sharing my story of living with lung disease.

Participants will be added to the LungNSPEI mailing list and may receive future communications not related to the Living Well with Lung Disease program. I understand I will be able to opt out at any time.

Are you applying for yourself or on someone's behalf?

Applying for myself

Applying for someone else