Better at Home Service Enquiry Application

Volunteer Cowichan’s Better at Home program provides non-medical, non-urgent support to seniors for day-to-day activities. The program is funded by the Government of BC and managed province-wide by United Way BC Healthy Aging.

Volunteer Cowichan does not provide emergency services. If this is a health emergency, please call 9-1-1.

Current age of person requesting services

"Eligibility for this program begins at age 65. ID is required at assessment. You are welcome to reapply once you meet the age requirement."

Are you filling this form out on behalf of a potential client?

Please note: We work directly with the person requesting services to understand their needs and determine the most appropriate support. Our services are intended for individuals who can communicate with our staff.

If you are unsure whether our services are a good fit, please call 250-748-2133 for assistance.

Name of Support Person who helped to complete this application.

First NameLast Name

Support Person's Contact:

Please enter a valid phone number.Format: (000) 000-0000.

Why is a support person assisting with this application? *Please select all that apply.

Other

Name of Person requesting services

First NameLast Name

Preferred First Name

Date of Birth

Date

Gender

Other

Phone Number

Area CodePhone Number

Email

example@example.com

Address

Street Address

#Apartment/Suite/Unit

CityProvince

Postal Code

Do you live alone?

Who else lives with you?

Other

Emergency Contact:

*Better at Home Service Enquiry Form