MitoCanada Face of Mito | Expressed Interest Form

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MitoCanada believes that we are stronger together. Celebrating the MitoCommunity includes sharing strategies, strengths and experiences through our stories. We are creating a Canada-wide anthology to honour Mito Heroes in every province. If you are interested in sharing your story with the MitoCommunity, we would like to get to know you. Please tell us about yourself.

Email *

First Name *

Last Name *

What Province/Territory do you live in? *

Have you or someone you care for been diagnosed with mito (i.e. parent, child or sibling)? *

I have been diagnosed with mito

My child has been diagnosed with mito

I care for someone diagnosed with mito

Other:

What mito diagnosis did you or the person you care for receive? *

What year did you or the person you care for receive a diagnosis? *

Please tell us a bit about yourself and your mito experience. *

Why do you want to share your mito story? *

Any other questions or comments to share

Submit

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