Victim/Survivor Information Request Form

Select your region:

Western Region MB SK AB BC YT NWTOntario RegionQuebec RegionAtlantic Region NS NB PE NL

Is this the first time that you are visiting our website?

YesNo

Was someone in your family killed in an impaired driving crash?

YesNo

If yes, who did you lose:

ParentChildPartnerSiblingGrandparentAunt/uncleNiece/nephewOther

Were you or a family member injured in an impaired driving crash?

I was injuredParentChildPartnerSiblingGrandparentAunt/uncleNiece/nephewOther

Was the driver charged with an impaired driving offence?

YesNoDon’t know

Have you consulted a personal injury lawyer?

YesNo

Have you been contacted by your local victim services?

YesNo

Would you like to receive information relating to Victim/Survivor Issues from MADD Canada?

YesNo

What topics would you like to receive information on?

Grief and LossCoping with InjuryA Victims Guide to the Criminal Justice systemA Victims Guide to Personal Injury LawMADD Canada Victim ServicesRemembering and Honouring victims and survivorsSomeone You Love Drove While ImpairedSurvivor GuiltHelping Children Deal with LossTeenager GriefWitnessed an Impaired Driving Crash

Additional comments:

First Name:

Last Name:

Address:

City:

Province:

ABBCMBNBNLNSNTNUONPEQCSKYT

Postal Code:

Email: