This is to nominate seniors living alone or in need of companionship( Grandpals) . Pl fill the detail of Grandpals.
Your Name
First Name
Last Name
Your Phone Number
Please enter a valid phone number.
Your Email
example@example.com
Your Address/City
*
Grandpal Details:
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Age
*
Address/City
*
Does the Grandpal live alone
*
Please Select
Yes
No
They have spouse/sons/daughters
*
Please Select
Spouse
Daughter
Son
Brother
Does the Grandpal have any illness history, pl mention
*
How do you know this Grandpal or anything else you would like to share
Please give reference of any two people whom you feel, who need our assist:
Full Name
City
Contact Number
Age
loneliness / illness
1
2
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Submit
Should be Empty: