CNIB Foundation Virtual Vision Mate Sign Up Form

Thank you for your interest in CNIB Foundation Virtual Vision Mate Program!

In order to complete your registration, we need to get to know you a bit better. Please be assured all information gathered is private and confidential.

Please note: Due to the volume of applications, it may take a few days for us to respond. We'll be in touch soon!

* Indicates a required field.

Contact Information

First Name

Last Name

Preferred Title

Preferred Personal Pronoun

Primary Phone (###-###-####)

Phone Type

HomeMobileWorkOther

Date of Birth

Address

City

Province

What CNIB Region in Ontario would you like to be referred to?

Postal Code

How did you hear about CNIB?

Area of Interest

Please choose your area of interest. You may pick one area of interest or both. You have the right to change your preference at any time.

I would like to engage in friendly conversations over the phone or online on a weekly basis.

I would like to have essential items (e.g. groceries or prescriptions) picked up and dropped off, as needed.

Declaration and Submission

Please read the following declarations carefully prior to checking the box stating that you agree to the outlined declarations and submitting your application.

I declare all the information provided on this form and in any other accompanying documents is complete and true in every respect.
I understand failure to completely and truthfully answer the questions asked of me, when discovered, will constitute grounds for immediate rejection of my application.
I understand that all personal information which become part of this application will be regarded as confidential pursuant to the Freedom of Information and Protection of Privacy Act.

I have read, understood and agree to the above declarations.

Yes

I hereby grant CNIB the right to reproduce, use, exhibit, display, broadcast, distribute, and create derivative works of any photograph/ video/ interview/ testimonial taken of me for use in connection with CNIB activities or promotion.

YesNo

For assistance please contact us at our Contact Centre: 1-800-563-2642.

Contact Information