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NEIGHBOURS HELPING SENIOR NEIGHBOURS COMMUNITY INITIATIVE 2021

REGISTRATION FORM TO RECEIVE FESTIVE GOODY BAG

Submission Deadline: Wednesday, December 15, 2021.  Questions? Email admin@hhca-london.ca

NOMINATOR'S FIRST NAME NOMINATOR'S LAST NAME
I AM REGISTERING FOR
Myself
a Family Member
a Neighbour
a Friend
Other
MY EMAIL ADDRESS MY CONTACT NUMBER SENIOR'S FIRST NAME SENIOR'S LAST NAME SENIOR'S HOME STREET ADDRESS SENIOR'S POSTAL CODE SENIOR'S LANDLINE NUMBER SENIOR'S MOBILE PHONE NUMBER SENIOR'S EMAIL ADDRESS SENIOR'S AGE SENIOR'S GENDER
WHAT ALLERGIES/DIET RESTRICTIONS DOES THE SENIOR HAVE?
Nut
Sugar
Milk
Scent
Chemical
Other - please indicate in additional comments
None
THE SENIOR LIVES
Alone
with a Spouse or Significant Other
with Family Members
with a Roommate(s)
THE SENIOR LIVES IN A/AN
House
Apartment Building
Co-operative
Condominium
Townhouse
Assisted Living/Long-Term Care Facility
Other
THE SENIOR HAS/IS A
Hearing Impaired
Visually Impaired
Physical Disability
Mobility Challenges
Chronic Pain/Illness
Mental Health Disorders -- social anxiety, panic
Permanent Shut-in
Quarantined due to Covid19
SENIOR'S FAVOURITE HOBBIES/ACTIVITIES
SENIOR'S SHIRT/BLOUSE/T-SHIRT SIZE
Small
Medium
Large
X-Large
XX-Large
XXX-Large
XXXX-Large
SENIOR'S SHOE SIZE WHAT ARE THE SENIOR'S FAVOURITE THINGS? SENIOR'S WISH LIST (list up to 3 items, $20-40.00 value) ADDITIONAL COMMENTS Submit