Creative Care Kit Signup 2022-2023

Creative Care Kit Program Signup

Creative Care Kit Sign-Up Form for new and previous participants. If you need any assistance completing this form, please contact Caitlin Roseen, Director of Community Engagement, at croseen@cvcoa.org or 802-595-6971.
Name:

First NameLast Name
Email:
example@example.com
Physical Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
What is your gender identity?

Other
Race
Ethnicity
What is your monthly household income (all sources)?
If filling out this form for someone else, please provide your full name:
Creative Activity Choice

Use this section to choose your Creative Care Kit activity. CVCOA will make every effort to provide kit recipients with their activity of choice.
Which of the following best describes you:
For returning participants who need supplemental supplies instead of a new kit, please list which supplies you need:
Which Creative Care Kit and activity binder would you like to receive?
Which of the following additional opportunities are you interested in? (Choose as many as you wish - these are subject to funding and teaching artist availability.)
Which of the following additional opportunities are you interested in? (Choose as many as you wish - these are subject to funding and teaching artist availability.)
Are there other artistic modes or creative activities you hope to engage in this year or in future years?
In 1-3 sentences, what is motivating you to engage in the creative process?
Creative Companion Preferences

Use this section to choose your preferences for connecting with others through creativity. CVCOA will make every effort to connect kit recipients with a Creative Companion volunteer. However, connections will be dependent on the number of participating volunteers and schedules of both parties. CVCOA cannot guarantee volunteers matches for all kit recipients.
Which of the following Creative Companion options are you interested in? (Choose as many as you wish.)
If you would like to be connected with a Creative Companion volunteer or you are serving as a volunteer, what is the best day of the week and time of day (in general) for your volunteer to connect with you?
In what ways would you prefer to connect? (Check as many as you wish.):
Do you have a preference for gender of your connection?

Other
Would you like to receive an iPad as part of your Creative Care Kit?
Do you have access to an internet connection in your home?
Would you like to receive more information about affordable internet options?
Please indicate your current comfortability / skill level with technology devices:
Do you have a friend or family member who would also be willing to help you practice technology skills?
Please describe any specific goals you have for how you would like to use technology (e.g. attending a wellness class, communicating with your Creative Companion volunteer, connecting with friends and family on social media, using Zoom to participate in community events):
Final Questions
How did you hear about the Creative Care Kit opportunity?(Choose the most relevant option if more than one applies.)

Other
Are you interested in participating in a research project to help improve this opportunity and help others learn more about the impact of creative engagement on a variety of health factors?
Would you like to receive a call from a CVCOA Options Counselor to discuss additional services like caregiver support, transportation, housing, in-home supports, public benefits, nutrition and food access options, etc.? (If 'Yes,' you will receive a call from the CVCOA Helpline team.)
Please add any questions or comments here:
In order to facilitate kit delivery and volunteer connections, CVCOA needs to share contact information like phone numbers, email addresses, and delivery addresses. All CVCOA volunteers complete an onboarding process which includes background checks. Please sign in the box below to give CVCOA permission to share contact information between volunteers and kit recipients.
Should be Empty:

Creative Care Kit Program Signup

Creative Activity Choice

Creative Companion Preferences

Final Questions