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Seniors Volunteer Program Referral

Name of senior being referred:

Phone #:

Address:

Gender:

Male

Female

Date of Birth:

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?

Yes

No

Please explain:

Is the senior aware of this referral?

Yes

No

Referral source:

Date:

MM slash DD slash YYYY

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

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制作特质营销

慈善注册 #119161750RR0001

反馈意见

这是一个安全的空间，您可以告诉我们圣艾丹学校哪些方面做得好，哪些方面可以改进。所有反馈都是匿名的。

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