Peer Support Request Form

Peer Support Volunteers assist many people each year, and those who have accessed services believe the support and encouragement they've received has been an important part of learning to live with kidney disease.

To request service you can either complete and submit the form below or you can call 1-866-390-PEER (7337) to speak with a program coordinator. Once we have been able to speak with you, and based on the information you provide to us, we will proceed to try and make a volunteer match for you.

The fields followed by an asterisk (*) indicate information that must be supplied to allow us to process your request and find the best volunteer match. Rest assured that all information provided will remain strictly confidential.

First Name *This question is required.

Last Name *This question is required.

City *This question is required.

Postal Code

Phone Number (including the area code): *This question is required.

Email Address *This question is required. This question requires a valid email address.

Spoken languages (other than English):

Please specify:

Comments:

With your consent, your personal information will be shared with the appropriate Kidney Foundation staff member, for the sole purpose of providing Peer Support services to you. This information will be kept strictly confidential and appropriately safeguarded. You may, at any time in the future, elect to change your mind and request to have your personal information removed from our records. *This question is required.

I consent to the collection, use, and disclosure of my personal information for this purpose.