Advocacy Ambassadors Needed for Manitoba Lobby Day

Name*

First NameLast Name

Date of Birth*

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Phone*

Please enter a valid phone number.

Mobile Phone

Please enter a valid phone number.

Work Phone

Please enter a valid phone number.

Email

example@example.com

I consent to receive electronic messages from Crohn’s and Colitis Canada,including emails, text messages, social network messages, contestnotifications, publications, e-newsletters, updates, announcements, events,promotions and invitations. This information will not be shared and you willalways have the option to unsubscribe.

Your Member of the Legislative Assembly (MLA)*

To find your MLA please visit youcount.ca and enter your address or postal code.

Please indicate all languages you are fluent in

EnglishFrenchOther

Please list any social media channels if you are active on social media

For applicants (Age 18 and over)

By submitting the online application I agree to abide by the Crohn’s and Colitis Canada’s volunteer Code of Conduct as well as any rules and requirements specific to Manitoba Lobby Day, including:

Consenting to Crohn’s and Colitis Canada may use my name and story in print, radio, television, web, social media to promote lobby day and Crohn’s and Colitis Canada’s mission and Advocacy priorities.
Applicants must be committed to further developing a relationship with their Member of the Legislative Assembly (MLA) post-lobby day.

Name of Parent or Legal Guardian

E-mail Address of Parent or Legal Guardian

example@example.com

Mobile Phone Number of Parent or Legal Guardian

Please enter a valid phone number.

Please list parent or guardian’s social media channels if active on social media

For parent or guardian (If applicant is under age 18)

By submitting the online application, I, as the applicant’s parent or legal guardian, agree to abide by the Crohn’s and Colitis Canada’s volunteer Code of Conduct as well as any rules and requirements specific to Manitoba Lobby Day, including:

Consenting to Crohn’s and Colitis Canada using my child’s name and story in print, radio, television, web, and social media (with appropriate safeguards) to promote lobby day and Crohn’s and Colitis Canada’s mission and Advocacy priorities.
That due to limitations of space and budget, only one parent or guardian may attend Manitoba Lobby Day.
Applicants must be committed to further developing a relationship with their Member of the Legislative Assembly (MLA) post-lobby day

Please verify that you are human*