Becoming a Citizen Partner – Registration Form 

 
Do you want to make a real difference in the health and social services network?
Do you want to get involved in your community? 
 
 
To apply to become a citizen partner with the Montréal West Island CIUSSS, please answer the questions below. The questionnaire should take about 4 minutes to complete.   

*Please note that Montreal West Island IUHSSC employees are not eligible to participate, however, we would like to thank you for your interest in the activities of the Citizen Partner Office
1. Do you work for the CIUSSS de l’Ouest-de-l’Île-de-Montréal? (Obligatoire)
2.Name
3.Email
4.Phone number
5.In what city/borough do you live? 
6.What gender do you identify as? 

Note: As provided by Statistics Canada, transgender, transsexual and intersex Canadians should indicate the gender (male or female) with which they most identify. 
7.What is your age group? (Minors are excluded)
8. What health-related issues interest you? 
9.What is your motivation for becoming a citizen partner?
10.How did you hear about the Citizen Partner’s Office?