Adopt An Elder

Circle of Care St. Louis - Adopt an Elder Sponsorship Form
Name

First NameLast Name
Organization/Group Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Contact Method

PhoneEmail AddressText
Sponsorship Preferences
How many elders would you like to sponsor?

1234
Would you prefer to sponsor an elder living alone or with a caregiver?

Living aloneWith a caregiverNo preference
How did you hear about the Adopt an Elder program?

Friend/FamilySocial MediaWebsiteOther
Would you like to make a financial donation in addition to your sponsorship?

Yes, I would like donateNo, I would just like to sponsor an elder
Gift Delivery
After you receive your profile and wishlist of your sponsored elder(s), please schedule a time to deliver your gifts to our office:

Delivery Deadline: All gifts must be delivered by December 15, 2024.
Preferred Delivery Date:

MonthDayYear
Date
Preferred Delivery Time:

MorningAfternoonEvening
Agreement
By submitting this form, I agree to sponsor an elder through Circle of Care St. Louis’ Adopt an Elder program. I understand the gifts I provide will directly support a senior in need this holiday season.
Signature

Clear
Date

MonthDayYear
Date
Thank you for your generosity!
For questions or assistance, please contact us at 314-873-3501
Should be Empty:

Circle of Care St. Louis - Adopt an Elder Sponsorship Form