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Mga programa
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Tungkol sa
Kumonekta

Seniors Volunteer Program Referral

Name of senior being referred:

Telepono #:

Address:

Gender:

Lalaki

Babae

Petsa ng kapanganakan:

MM slash DD slash YYYY

Ethnicity:

Email:

Mobility Issues:

Medical Information:

Service Needs

Driver Support

Transportation to and from appointments. Volunteer will stay with the senior and help during the outing as needed and return the senior safely back to their residence.

Number – driver support

Estimated hours per week requested

Shopping Support

Assist senior by escorting them on shopping trips and help with purchasing and putting away items.

Number – shopping support

Estimated hours per week requested

Friendly Visiting

Phone calls or home visits with seniors.

Number – friendly visiting

Available hours per week

Caring Companionship

Accompany seniors out into the community for events, walks, appointments etc. Volunteer will help isolated and lonely seniors stay connected.

Number – friendly visiting

Estimated hours per week requested

Interests and specific areas of need:

Immediate connection requested?

Oo

Hindi

Please explain:

Is the senior aware of this referral?

Oo

Hindi

Referral source:

Date:

MM slash DD slash YYYY

For further questions or concerns, please contact our Volunteer Coordinator at carlac@staidanssociety.ca o tumawag 780.743.4370, Ext. 4.

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Charitable Registration #119161750RR0001

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