Refer a Senior

Refer a Senior

Note: This form is still being created. We apologise for the inconvenience.

Senior Referring Application

Welcome to the Adopt a Senior program! Our aim is to make life a little brighter for the senior's in our community!

Person Referring Information

Email address *
Tel contact Nº

Care Home / Assisted Living Community (if applicable):

Senior Person Being Referred

Please fill out the below information:

Name *
*Please note: If a name cannot be given due to privacy issues, we must receive at least a first and last initial for organizational purposes.

Gender * - Male - Female
Address *
*Please note: If the senior currently resides at a senior's own home, please be sure to add the name of the residence to this portion of the application. Otherwise add the name of the care home.

Phone Number *

Age *

Please list 5 special items they would wish to receive during the course of this year!
*Please note: Wish list items can be anything from clothing to slippers, books, music, movies, toiletries, games and more! If clothing items are being added, please ensure to be as descriptive as possible; size, colour, material. *Don't forget to include their favourite treat!

Is there anything else you wish to tell us that would make this year extra special?

Allergies or Dietary Restrictions *
Puree diet

Is the senior willing to meet the donor?
In the past, donor's have been interested in meeting their senior (as well as delivering a gift at Christmas time or Birthday). If they are willing to meet the donor, please let us know below.
Approval: *
Please select one!

I am nominating a senior and I have permission from that senior to submit this application
    Describe your relationship to the senior: friend | caregiver | social worker | neighbour
I am a family member applying on behalf of a senior and have permission to submit this application
  Daughter | Son | Granddaughter | Grandson | Other:_____ (relationship)

Have questions? Please feel free to leave your questions here.