Bradley Centre Program Assistance Form
We’re here to help! If you’d like to participate in our programs but need assistance with membership, workshop fees, a punch card for Connections Cafe, or something else, please fill out this form. Your information will be kept confidential. We may also share other relevant assistance information with you, such as community resources or additional support programs.
Name
*
First Name
Last Name
Email
*
If you do not have an email please answer: noemail@noemail.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Town/City
*
Type of assistance requested
*
Free Punch Card
Free Membership
Workshop Registration Fee
Other
Age Range
*
Under 55
55-65
65-74
75+
Which workshop are you interested in?
Which of the following describe your current situation? (Check all that apply)
Living on a fixed or limited income
Experiencing unexpected expences or changes
Receiving disability or income assistance
Other
Is there anything else you would like us to know?
I confirm that I am experiencing financial or personal circumstances that make it difficult to afford the cost of programs or services.
*
Yes
I agree to the confidential use of my information for reporting and program improvement purposes. This includes reporting age demographics and general locations (e.g., neighborhood) to help us better understand and serve our community. Your name and personal details will only ever be shared if required by law
*
Yes
Submit
Should be Empty: