Montana Stroke Survivor Connections

Volunteer Intake Survey

Are you interested in volunteering as a stroke peer connection?

If you are a stroke survivor (or caregiver) interested in volunteering as a peer mentor for our Montana Stroke Survivor Connections program, please complete the brief intake survey below. We will be in touch soon with further details. Thank you for your interest!

Name

Phone Number

Secondary Phone Number (Optional):

Street Address

Apartment/Suite (if not applicable, please enter "NA")

City

State

Zip Code

Your relationship to Stroke:

I am a stroke survivor I am the caregiver of a stroke survivor Other (if "other", please explain below):

If you answered "Other" to the question about, please explain below.

How did you hear about this program? (select all that apply).

Google Search Facebook Instagram BIAMT Newsletter BIAMT Website Primary Care Provider/Physician Word of mouth Other

Is there anything else you would like us to know?

I give my permission to share the above information with the Brain Injury Alliance of Montana to be enrolled in Montana Stroke Survivor Connections. I am aware that the information that I provide will be provided to BIAMT staff and volunteers.

I ACCEPT

By using this form you agree with the storage and handling of your data by this website.

I ACCEPT

Mission Statement

“To create a better future for those impacted by brain injury through awareness, support, advocacy, community engagement, and prevention.”

501(c)(3) - Nonprofit

EIN: 81-0452877

Facebook Twitter Instagram Linkedin

Montana Stroke Survivor Connections Volunteer Intake Survey

Are you interested in volunteering as a stroke peer connection?

Montana Stroke Survivor Connections

Volunteer Intake Survey