MACCA Focus Group RSVP Form

Markham African Caribbean Canadian Association (MACCA) Focus Group RSVP
Thank you for your interest in participating in our focus group. We'd like to better understand how members of the Afro-Caribbean community have been affected and continue to be challenged by this Covid-19 pandemic. MACCA, through the generous funding of the United Way and as facilitated in part by the Government of Canada is working to provide tailored covid-relief services to the Afro-Caribbean community located in York Region. For this reason, we'd really appreciate getting to know you and your needs better! Thank you for taking the time to fill out this form.
Do you consent to receiving communication from MACCA? *

Yes No
First Name *
Last Name *
Phone Number *
E-Mail *
Please select which date you will be attending our focus group: *
Please select the ethnicity you most closely identify with: *

Black (Caribbean - Bermuda origin & descent) Black (African origin & descent) Mixed Heritage
What city/town are you located in within the York Region? *
(example: Richmond Hill)
If you or any members of your household fall under any of the below age ranges, please tick as many boxes that apply. *

0 to 2 years 3 to 10 years 11 to 17 years 18 to 24 years 25 to 34 years 35 to 44 years 45 to 54 years 55 to 64 years 65 or older Prefer not to answer
How has the pandemic affected you and/or your family? *
(example(s): decreased wages, increased stress, food insecurity, isolation etc.)
Marital Status: *

Single, never married Married or domestic partnership Widowed Separated Divorced Prefer not to answer
Employment Status: *

Employed Full-Time Employed Part-Time Currently Unemployed Business Owner/Entrepreneur Prefer Not to Answer
What is the highest level of education you have completed? *
Do you identify as a person living with a disability? *

Yes No Prefer not to answer
Would you be interested in accessing free health and wellness Zoom webinars facilitated by a nurse practitioner? *

Yes No Prefer not to answer
Should be Empty:

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