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Seniors Social Inclusion

Seniors Social Inclusion

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sissip@pics.bc.ca

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Home
Services
RESOURCES
Partners
Background
NEWS
CONTACT

Seniors Centre Without Walls Registration 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

Dream-Theme — truly premium WordPress themes

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

Chinese (Simplified)