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Seniors Social Inclusion
Seniors Social Inclusion
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Services
Connecting Generations
Seniors Hub
Surrey SHARES
Seniors Centre Without Walls
Seniors on the Go
WALKit
Promoting Inclusion for Indigenous Elders
RESOURCES
Partners
Background
NEWS
CONTACT
sissip@pics.bc.ca
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Home
Services
Connecting Generations
Seniors Hub
Surrey SHARES
Seniors Centre Without Walls
Seniors on the Go
WALKit
Promoting Inclusion for Indigenous Elders
RESOURCES
Partners
Background
NEWS
CONTACT
Seniors Hub Registration Form
Please enable JavaScript in your browser to complete this form.
Name
*
First
Last
Email
*
Phone No.
Which age group best describes you?
*
15-24
25-34
35-54
55-59
60-64
65-69
70-74
75-79
80-84
85-89
90-94
95+
Prefer not to answer
Do you identify as:
Male
Female
Non-Binary
Other
Prefer not to answer
Which neighbourhood do you currently live in?
Cloverdale
Fleetwood
Guildford
Newton
South Surrey
Whalley
Other, please specify
Don't know
Prefer not to answer
If other, please specify
What is your ethnic or cultural origin background? Please choose all that apply.
Aboriginal ( that is First Nations, Metis or Inuit)
White (e.g. European Descent)
South Asian (e.g., East Indian, Pakistani, Sri Lankan, etc.)
Chinese
Black (e.g. African or Caribbean)
Filipino
Latin American/Hispanic
Middle Eastern /Arabic
Southeast Asian (e.g., Vietnamese, Cambodian, Laotian, Thai, etc.)
West Asian (e.g., Iranian, Afghan, etc.)
Korean
Japanese
Other, please specify
Prefer not to answer
Don’t know
If other, please specify
Do you identify as: (check all that apply)
a person with a physical or disability
a person with mental health issues
a person with an addiction or substance use issue
an immigrant or newcomer to Canada
a member of the LGBTQ+ community
a person who is homeless
a person who is a caregiver/carer
Prefer not to answer
What are you hoping to get by participating in this program?
Where did you hear about this project?
Friends/Family
Newspaper
PICS
City of Surrey
Brella Community Services Society
Sources
UNITI
FRAFCA
Facebook
Instagram
SISSIP Website
Other
If other, please specify
Submit
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