Seniors' Living Life Project

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

AWAH (Ageing Well At Home) in-home support

Email *

Name of the person that informed you about the Living Life Program? *

Your First Name *

Your Last Name *

Phone number *

Age *

Gender *

Male

Female

Other:

Address *

In which city do you reside?
*

Please note that is program is only available to residents of Windsor, Kitchener and Hamilton

Windsor

Kitchener

Hamilton

Preferred method of contact *

First and Last name of emergency contact *

Phone number of emergency contact *

Relationship to emergency contact *

Are you an immigrant *

Yes

How long have you been in Canada *

What is your annual income *

Less than 20,000 Dollars

20,000 to 30,000 Dollars

31,000 to 40,000 Dollars

41,000 to 50,000 Dollars

Above 50,000 Dollars

Do you have any disability *

Visual

Physical

Mental

Required

Do you require any special arrangements for mobility?
*

Yes

What type of services do you require? (Other option is subject to availability) *

Light housekeeping

Hot Meals (Delivered or Pickup)

Home meal preparation (we will provide the ingredients)

Home maintenance (minor repairs)

Transportation

Snow removal

Friendly visits

Lawn care

Wellness check up calls

Other:

Required

Do you have any allergies or dietary restrictions?
*

Are there any medical conditions we should be aware of?
*

What are your hobbies and interests?

Do you have any specific expectations or suggestions for our program?

Any other comment

Thank you!

Privacy notice

As part of the application process, the Nigerian Canadians for Cultural, Educational, and Economic Progress collects certain personal information from applicants, including demographic and contact information. The information is collected to assess eligibility for the program, evaluate the application, and communicate with applicants. We may share the information collected with the program funders for the following purposes: evaluating the effectiveness and impact of the program, reporting and compliance requirements, and furthering the goals and objectives of the program.

By signing below, you consent to collecting, using, and sharing your personal information as described in this notice. You can withdraw your consent at any time by contacting us at info@ncceep.com.

I agree

A copy of your responses will be emailed to the address you provided.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms