Senior Champions Program Client Application

This is a volunteer-provided respite program designed to give caregivers a much needed break from their care-giving duties and offer companionship and stimulation to an adult aged 60 and over with mild cognitive or physical disabilities. The program may include such areas as art, music therapy, therapeutic gardening and health and wellness programs.The Senior Champions Program accepts people from all faiths.There is no fee to attend.

If you are interested in enrolling an adult in the program, you must:

- have your medical doctor fill out a TB Test Form, and

- please fill out the client application below:



Personal Information

In case of emergency, please contact:

Primary Physician:

Medical Information

Social History

Other Notes

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