CLIENT APPLICATION/REFERRAL FORM

Please complete the information below and someone from our office will connect with you within 48 hours.
If you require immediate assistance, please call 705-789-6676 M-F 9am-4pm.

Must be 60 years of age or older (excluding Meals on Wheels)
Must live in your own home or retirement home
Must live within the Huntsville or surrounding area

CLIENT INFORMATION

Name

First Name

Last Name

Address

Town, Province

Postal Code

Date of Birth

MM

DD

YYYY

Service Request

Transportation

Social Events

Friendly Visiting

Frozen Meals on Wheels

Hot Meals on Wheels

Grocery Delivery

Income Tax Preparation

Additional Information

CONTACT INFORMATION

Contact name is same as above

First Name

Last Name

Phone

(###)

###

####

Email

Relationship to Client

REFERRAL SOURCE - Name/Company/Phone Number

Hosptial to Home Client

Notice and Consent

Keeping Your Personal Information Private is Important to Us. You, as an individual, have a right to know how we collect, use and disclose personal information. You have a right to expect that, to the best of our ability, your personal information held by us remains accurate, confidential and secure. Muskoka Seniors collects, uses, discloses and stores facts about you and your health. These facts are collected to help provide volunteer support services. We use this information and share it only with those who need to know that information.

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CLIENT APPLICATION/REFERRAL FORM

Please note, remainder of application will be completed over the phone.

< Back to Become a Client Page