Telephone Reassurance Service Client Application
Personal Information
Client's Full Name:
*
First Name
Last Name
Client's Phone Number:
*
Client's E-mail:
*
example@example.com
Client's Age:
Client's Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Service Needs
What are you looking for in the Telephone Reassurance Service?
How often would you like to receive calls?
Interests and Preferences:
Do you have any hobbies or interests you'd like to share with a volunteer?
What languages do you speak?
Are there any specific topics you enjoy discussing?
Availability
What days and times are most convenient for you to receive calls?
Health and Safety
Do you have any specific health concerns or safety issues we should be aware of?
Emergency Contact
Emergency Contact Name:
First Name
Last Name
Relationship:
Phone Number:
Please enter a valid phone number.
Email:
example@example.com
Do you consent to having your calls monitored or recorded for quality assurance purposes?
Do you have any preferences or requirements for your volunteer match?
Additional Information/Comments
CONTACT US
Should be Empty: