Seniors on the Go

First name* Last name* Birthday* Home phone* Mobile number Email

Ethnicity*

If “Other”, please specify your ethnicity*

Primary language*

If “Other”, please specify your language*

Residency status* Arrival date into Canada

Emergency contact name* Relationship to senior* Emergency contact phone*

Do you smoke?*

Yes No

Do you have any pets?*

Yes No

Do you have access to the Internet?*

Yes No

Mobility Vision impairment Hearing impairment Speech impairment

Seniors on the Go — Intake & Referral Form