Media Candidate Form
Thank you for agreeing to participate in media interviews. Please note that specific individuals have been designated as Food
Allergy Canada spokespersons and that these persons only can speak on behalf of the organization. Others will be asked to
provide their views as individuals who have a ‘connection’ with food allergies, e.g. you have food allergies, are a parent of a child
with food allergies, physician, etc. We appreciate your ongoing contribution to raising public awareness about food allergies!
Food Allergy Canada
Date
Name
Partner’s Name
About yourself
What is your connection to food allergy (F/A)?
I have F/A
Child - F/A
Physician
Other:
Specify
What types of interviews are you willing to do?
TV
Print/Web
Radio
Other:
Child(ren)
Other:
Who is willing to participate in interviews?
Me
Partner
Your Contact Information
Cell #
Home #
Work #
Days/Hrs
Email Address
Home Address &
Major Intersection
Business Address
& Major
Intersection
Confidential: Your information will help us quickly connect journalists with individuals,
based on the topics they are covering. Your information will not be shared with others.
Media Candidate Form
Personal History
Complete the following information for each of the participants affected by food allergies/anaphylaxis.

Name: Provide first/last name of child if different from your own.

Date of Birth (DOB): For children only. Provide Month/Year of Diagnosis (if you know).

Allergic reactions: History of reactions (e.g. have you/child had a reaction; briefly explain experience)

Media Participation: Have you/your child done other interviews? Please indicate if your child is willing to be interviewed on camera.
Name (first/last)
DOB &
Year of
Diagnosis
Allergies / Asthma / Other
Allergic Reactions
Anything special you’d like us to know about yourself, e.g. you/your child have been interviewed before, you have a blog?
Confidential: Your information will help us quickly connect journalists with individuals,
based on the topics they are covering. Your information will not be shared with others.