Back to Society of Seniors Caring About Seniors
Please fill out the following and submit along with your application fee (by mail or in person) to Room 106, 7814 83 Street, Edmonton, Alberta, T6C 2Y8.
First Name _____________________________ Last Name _____________________________
Second Member's Name (if applicable) ___________________________________________
Address ________________________________________________________________________
Postal Code _____________________________ Telephone ____________________________
Emergency Contact Name _____________________________ Telephone _________________
_____ Transportation
_____ Household Service
Year of Birth: ______________
_____ government pension
_____ company pension
_____ government supplement
_____ other
_____ need assistance
_____ use walker
_____ use oxygen
_____ vision impaired
_____ hearing impaired
_____ poor memory
_____ confusion
_____ family
_____ community
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