Skip to content

Seniors Social Inclusion

Seniors Social Inclusion

HOME
Services
RESOURCES
Partners
Background
NEWS
CONTACT

sissip@pics.bc.ca

Facebook page opens in new window Twitter page opens in new window Instagram page opens in new window

HOME
Services
RESOURCES
Partners
Background
NEWS
CONTACT

Intake Form – Seniors Centre Without Walls

Name *

First

Last

Email *

Phone No.

Age Range

55-59
60-64
65-69
70-74
75-79
80+

What is your gender?

Male
Female
Non-Binary

Which neighbourhood do you live in?

Cloverdale
Fleetwood
Guildford
Newton
South Surrey
Whalley

Which ethnic group do you identify as?

Asian
Black and/or African American
Caucasian
Mètis
Inuit
Indigenous
Latino
Middle East/Arabic
South Asian
Other- Please specify
Prefer not to say
Other

If other, please specify

Which category best describes you?

Senior 55+
Senior with a Disability
Immigrant Senior
Indigenous Senior
LGBTQ2+ Senior
Senior suffering from Addiction
Homeless Senior
Senior Suffering from Abuse
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
Seniors Come Share Society
Sources
Semiahmoo House Society
FRAFCA
Facebook
Instagram
Twitter
SISSIP Website
Other

If other, please specify

© Surrey Intercultural Seniors Social Inclusion Partnership Network

The SISSIP Network website design and layout is inspired by a previously successful NHSP funded project, the Hamilton Seniors Isolation Impact Plan.

Chinese (Simplified)