Asthma Ambassador

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Personal Information

Last Name:

First Name:

Address:

City:

Province:

Postal Code:

Email:

Preferred Phone Contact #:

Home Work Cell

Best time to call:

Morning Afternoon Evening Weekend

What is your connection to asthma?

How did you hear about the Asthma Ambassadors program?

Program Information

So we can tailor information to the places you live, work and play, please let us know which cities or towns you frequently visit:

I am currently in school, and could serve as a resource at (campus)

What languages can you speak fluently?:

English French Other

I am already a NAPA member
Please sign me up as a NAPA member (for FREE!) For more information about NAPA, please click here.

Privacy Statement

The Asthma Society of Canada respects your privacy. The personal information you provide will be held in confidence and used only as described. We do not rent or trade names, and your information does not pass outside the Asthma Society of Canada. By clicking ‘Submit’, you agree that you have read this privacy statement and agree to receive information related to your participation in the Asthma Ambassadors program.

If you are printing and mailing this form, please address it to ‘NAPA’ at the address below.

4590 Yonge Street, Suite 2306
Toronto, Ontario
Canada
M2N 6K1

Charitable Registration No. 89853 7048 RR001

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