Virtual Respite Request Form

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Thank you for your interest in the Dementia Society's Virtual Respite Program. If you would like to be matched with a volunteer for Virtual Respite Visits, please fill out the below form.

A staff member from the Dementia Society will contact you within 1-2 business days to discuss your request in more detail and provide you with more information.

First Name *

Last Name *

Phone Number *

Email Address *

I am looking for support (check all that apply): *

Weekday mornings

Weekday afternoons

Weekday evenings

Weekend mornings

Weekend afternoons

Weekend evenings

Required

I am looking for support primarily in (check all that apply): *

English

French

Other:

Required

I am primarily interested in:

Light telephone chatting/social visits

Pre-planned virtual activities (music, games, puzzles, photo slideshows, etc.)

Other:

I am a current client of the Dementia Society: *

Yes

I don't know

Submit

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