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Keeping Seniors Warm is a United Way program open to residents of Greater Sudbury who are over the age of 55 and in need of winter clothing to keep them safe over the cold winter months. Participants will be accepted on a first come, first served basis, however, we will try to accomodate individuals who are new to the program.

* Participant Name:

* Participant Address:

* Participant Phone Number:

* Referring Agency:

* Referral's Name:

* Referral Agency/Individual Phone Number:

Does the participant have any medical conditions of which we should be aware? (optional):

Has the participant participated in Keeping Seniors Warm in the past?

Yes

If yes, please indicate the last year of participation:

Will the participant require a bust ticket to get to and from the shopping event?

Yes

N/A

If the participant requires bus tickets, please provide address to send the bus tickets to:

Emergency Contact

Name:

Phone Number:

Relationship to participant:

Items marked with an asterisk(*) are required

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Keeping Seniors Warm - 2023 Agency Referral