Recharge & Rejuvenate Form

Recharge and Rejuvenate Form

To be completed by a relative, caregiver, Power of Attorney, or trusted individual acting on behalf of the senior or veteran participant.
Welcome to Up Giving Village!
We’re so grateful you’ve connected with Up Giving Village.
This form gathers the essential information we need to connect your loved one with friendly, non-medical companionship through our Village Visits and TelePal programs. These moments of connection are designed to reduce social isolation, lift spirits, and ease the burden on caregivers.

Thank you for trusting us to be part of your village. If you have any questions along the way, we’re here for you. 💚
— The Up Giving Village Team
Section 1: Referring Person (You)
Full Name *

First NameLast Name
Relationship to Participant*
Email*
PHONE NUMBER*
Please enter a valid phone number.
PREFERRED CONTACT METHOD*

PhoneEmailTextOther
Do you have permission or legal authority to provide this information on behalf of the participant?

YesNo
Are you completing this form on behalf of a facility or organization (e.g., nursing home, assisted living, or personal care home)?

YesNo
Facility/ Organization Information
Facility/Organization Name*
Type of Facility*
Facility Contact Person*

First NameLast Name
Title/Role of Contact*
Facility Phone Number*
Please enter a valid phone number.
Facility Email*
example@example.com
Facility Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Number of Residents to Be Served*
Please add all participating residents using the link below. *

https://form.jotform.com/252047028742151
Preferred Volunteer Schedule
(describe group visit options, call times, etc.)
Special Instructions/Notes

Recharge and Rejuvenate Form

To be completed by a relative, caregiver, Power of Attorney, or trusted individual acting on behalf of the senior or veteran participant.
Section 4: Emergency Contact
Emergency Contact *

First NameLast Name
Relationship to Participant*
Email*
PHONE NUMBER*
Please enter a valid phone number.
Section 5: Consent & Agreement
Please read carefully before submitting: Up Giving Village’s Recharge and Rejuvenate program offers volunteer-based, non-medical companionship designed solely to reduce social isolation, loneliness, and caregiver burnout. We do not provide any professional, clinical, or home health care services. This program is not a substitute for medical treatment or supervision. Volunteers are background-checked and trained for social engagement only. The referring person affirms that the home is safe for visits or phone calls. Program participation is completely voluntary and may be paused or ended at any time by either party.*

I have read and agree to the above Consent & Agreement. (Required)I give permission for Up Giving Village staff/volunteers to contact and visit the participant as requested. (Required)
Section 6: Legal Notice, Waiver of Liability, and Photo/Media Consent
Final Consent Options*

I have read, understand, and voluntarily agree to the above Waiver of Liability and Media Release Authorization. (Required)I DO NOT give permission for the participant to be included in any photo, audio, or video media. (Optional)

Support Recharge & Rejuvenate

Loneliness Is Heavy. You Can Help Lift It. Across Georgia, too many seniors and veterans sit in silence—days without a visitor, weeks without a phone call, months without meaningful connection. Recharge and Rejuvenate exists to change that. Your donation helps us send trained volunteers into living rooms, nursing homes, and quiet phone calls—bringing conversation, compassion, and care. Whether it’s a card game, a shared memory, or simply sitting in silence so someone doesn’t have to feel alone, you make those moments possible. A small gift helps us provide comfort kits, supplies, and volunteer support that brighten dark days and ease the weight on caregivers too tired to keep going alone. Together, we’re not just serving—we’re restoring dignity, connection, and hope. Because no one should ever feel forgotten. We are the Village. Thank you for giving.

Donation Amount

USDLoneliness Is Heavy. You Can Help Lift It. Across Georgia, too many seniors and veterans sit in silence—days without a visitor, weeks without a phone call, months without meaningful connection. Recharge and Rejuvenate exists to change that. Your donation helps us send trained volunteers into living rooms, nursing homes, and quiet phone calls—bringing conversation, compassion, and care. Whether it’s a card game, a shared memory, or simply sitting in silence so someone doesn’t have to feel alone, you make those moments possible. A small gift helps us provide comfort kits, supplies, and volunteer support that brighten dark days and ease the weight on caregivers too tired to keep going alone. Together, we’re not just serving—we’re restoring dignity, connection, and hope. Because no one should ever feel forgotten. We are the Village. Thank you for giving.

Payment Methods

Credit Card

Cash App Pay

Afterpay

Should be Empty:

Recharge and Rejuvenate Form

Facility/ Organization Information

Recharge and Rejuvenate Form

Recharge and Rejuvenate Form

Support Recharge & Rejuvenate

Payment Methods