Community Club Inquiry

Please take a few minutes to fill in this form so that we can best help you.

If you are not able to fill in the form or have any questions, please call us on (03) 9636 3321 or email yosi@ccare.org.au.
Enquiry type*
I am filling in this form for myselfI am filling in this form on behalf of another person

In what year were you born?*
In which suburb do you live?*
I am a recipient of a Home Care PackageI am on a waitlist to receive a Home Care PackageI am not sure if I am a recipient of a Home Care PackageI live in an Aged Care Home
Who is your Home Care Package provider?*
Which aged care home do you live in?*

MaleFemaleI have no preferencesOther
Please let us know any other information that you'd like us to know to help us find an appropriate person to visit you.*
Feel free to add any relevant notes here
How much do you like to talk?

1

2

3

4

5

1 is Minimal, 5 is Maximal
How much do you like to listen?

1

2

3

4

5

1 is Minimal, 5 is Maximal
No preferenceJewishSurvivorOther
C CareB'nai B'rithOther oganisation in the J-comAged Care providerFriends and FamilyOther

I authorise C Care to collect this information for the purpose of enabling my participating in C Care's services
Should be Empty: