Senior Citizen Support Request Form
Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you live alone?
*
Please Select
Yes
No
Phone Number 1
*
Must include area code
Format: (000) 000-0000.
Email
example@example.com
Emergency contacts with phone numbers
*
List all pets in the home (if applicable)
Please select the areas of service are you requesting assistance/information. A representative will reach out to you within 3-5 business days.
*
Phone Buddy: Wellness phone calls to help keep people connected.
Social Wellness Visits: In person visits by vetted companions who offer meaningful conversation, fun activities and healthy engagement.
Meals and a Visit Program (MVP): Hot meals delivered for homebound individuals.
Errand Runner/Chauffer: From grocery store trips to doctors appointments and everything in between.
Excelsior Springs Transportation Services: Curb-to-curb public transportation system for ES citizens is a fixed route service with minor deviations within city limits.
Neighbors Helping Neighbors: Connects volunteers, volunteer groups, and organizations with eligible Excelsior Springs residents whose homes require maintenance and/or repair.
Universal Design: Makes day-to-day living and tasks possible by allowing a person to remain independent in their home for as long as possible by implementing universal design elements.
Silver Prom: An afternoon of celebration designed specifically for guests 60 and older.
Snow Angels: Snow removal services for elderly and/or disabled individuals.
Senior Center: A place to socialize, participate in activities, and enjoy a hot nutritious meal during the week. The Senior Center offers a variety of activities from card games to fitness classes and many other health programs.
Other
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