Pre-registration form 01. Information 02. Medical 03. Other informations 04. Respondent 1 05. Respondent 2 06. Respondent 3 07. Worker Name Basic general information: place where you live * Montréal, Mercier Hochelaga Maisonneuve Montréal, Pointe-aux-Trembles/Montréal-Est Montréal, Rosemont-La Petite-Patrie Montréal, Rivière-des-Prairies Lac-des-Plages - Municipality of Lac-des-Plages Mascouche - City of Mascouche Sainte-Élisabeth - City of Sainte-Élisabeth Saint-Lin-Laurentides - City of Saint-Lin-Laurentides Lavaltrie - Maison des Ainés de Lavaltrie / City of Lavaltrie MRC d'Argenteuil Montmagny Sherbrooke Other Last name and first name: * Gender: * Man Women Couple Date of Birth: * The subscriber lives: * Alone In a relationship Langue: * French English Other (give details) Other language: E-mail: Civic number and street: * Apartment City: * Province: * Alberta Colombie-Britannique Île-du-Prince-Édouard Manitoba Nouveau-Brunswick Nouvelle-Écosse Ontario Québec Saskatchewan Terre-Neuve-et-Labrador Nunavut Territoires du Nord-Ouest Yukon Country: * Canada Postal code: * Phone: * Cell phone: Do you use text messages? * Yes No I don't have a cell phone Does your residence have an anti-theft system? * Oui Non Medical information: During your travels, you move: * Alone With the help of a cane With the help of a walker With a wheelchair Other (Specify) Other travel restrictions Do you have hearing limitations? * No Yes, but without hearing aid Yes with hearing aids (Specify if right or left ear) hearing limitations ear left ear right Do you have visual limitations? * No Cataracts Glumoca Others (Specify) Other visual limitations Do you have cognitive limitations? * No Alzheimer's disease Dementia Others (Specify) Other cognitive limitations What is your degree of autonomy? * Good Partial Do you have any other medical conditions that you should know to help you in an emergency? (Ex: Diabetes, epilepsy, hypertension, allergy etc.) Comments: Other useful information: Do you have a pet? If so, specify the breed and name in the comments. * No Dog Cat other (specify in comment) Comments: Frequency (days when you want to receive your calls) * Everyday Sunday Monday Tuesday Wednesday Thursday Friday Saturday At what time would you like to receive your call? (Between 7:30 AM and 11:30 AM) * 7:30 AM 7:45 AM 8:00 AM 8:15 AM 8:30 AM 8:45 AM 9:00 AM 9:15 AM 9:30 AM 9:45 AM 10:00 AM 10:15 AM 10:30 AM 10:45 AM 11:00 AM 11:15 AM 11:30 AM Respondent 1: Last name and first name * Language: * French English Phone: * Cell phone: Email: Link with the member? * Friend Neighbour Child Brother or Sister Other (Specify in comments) Other links: Does the respondent have an emergency key? * Yes No If the member's residence has an anti-theft system, does the respondent know the code? * Yes No There is no system against theft Respondent 2: Last name and first name Language: French English Phone: Cell phone: Email: Link with the member? Friend Neighbour Child Brother or Sister Other (Specify in comments) Other links: Does the respondent have an emergency key? Yes No If the member's residence has an anti-theft system, does the respondent know the code? Yes No There is no system against theft Respondent 3: Last name and first name Language: French English Phone: Cell phone: Email: Link with the member? Friend Neighbour Child Brother or Sister Other (Specify in comments) Other links: Does the respondent have an emergency key? Yes No If the member's residence has an anti-theft system, does the respondent know the code? Yes No There is no system against theft Identification of the speaker: First and last name of the speaker: Organization or Municipality: Borough or City: Email: Phone:
