Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
Prov
Postal Code
Phone Number
*
Please enter a valid phone number.
Email
example@example.com
Yearly Income
*
Income statement will be required, if accepted into the program.
Are you over 55?
*
Yes
No
Any health/ disability/ limitations you'd like us to know about.
Programs you're applying for:
*
Meals on Wheels
Lawn Care
Home Maintenance
Transportation (Taxi)
Drop-off Program
If not selected for your chosen program(s), would you like to be added to the waitlist?
Yes
No
Meals on Wheels
Please complete this section ONLY if you're applying to our Meals on Wheels Program. *There is a fee associated with this program.
Meals on Wheels Fee Structure
Household Income
Amount You Pay
Amount We Subsidize
At or below $25,000
$5.00
$5.00
$25,001 - $50,000
$7.00
$3.00
$50,000 or 3rd Party Orginazation
$10.00
Please choose which delivery days you're applying for (hot meals).
Monday
Tuesday
Wednesday
Thursday
Are you interested in our new frozen meals option? There is no specific day associated with frozen meals.
Yes
No
Lawn Care
Please complete this section ONLY if you're applying to our Lawn Care Program. *This is a free program.
Approximate size of lawn
Approximate number of times your lawn was mowed last year
Average amount spent on lawn care last year
Home Maintenance
Please complete this section ONLY if you're applying to our Home Maintenance Program. *There are fees associated with this program - home owner must supply all building materials. (Town House supplies free labour and job tools.)
Type of project(s) you're requesting support for
Transportation
Please complete this section ONLY if you're applying to our Taxi Program. *This is a free program.
Typical number of essential trips you take within Glace Bay per week.
Typical number of essential trips you take to Sydney per week.
Other trip information you'd like us to know (eg. you take one trip to Sydney per month, etc.)
Snow Removal
Please complete this section ONLY if you're applying to our Snow Removal Program. *This is a free program.
Length/ size of driveway
Type of driveway
Paved
Gravel
Dirt
Do you require an early morning plow? (You have to get to work, homecare needs access, etc.)
Yes
No
Drop-off Program
Please complete this section ONLY if you're applying to our Volunteer Drop-Off Program. *This is a free program.
Please describe the type of errands requiring support
Number of times per week errand support is required
Would you like to receive information about other Town House programs or volunteer opportunities? Choose all that apply.
*
Please send me info about other Town House programs
Please send me info about volunteer opportunities
Please send me info about how to support Town House
No thank you, please don't send me any additional info
Is there any other information you'd like to provide?
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