Skip to content
Seniors Social Inclusion
Seniors Social Inclusion
HOME
Services
Seniors Centre Without Walls
Seniors Engagement Through Technology
Surrey SHARES
Connecting Generations
Seniors Hub
Promoting Inclusion for Indigenous Elders
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
Seniors Centre Without Walls
Seniors Engagement Through Technology
Surrey SHARES
Connecting Generations
Seniors Hub
Promoting Inclusion for Indigenous Elders
RESOURCES
Partners
Background
NEWS
CONTACT
Intake Form – Seniors Centre Without Walls
Please enable JavaScript in your browser to complete this form.
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
Submit
Go to Top
English
Punjabi
Chinese (Simplified)
Korean
Arabic
Filipino
French
English