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Become a Service Recipient

Sign up to become a service recipient at Glover Park Village! Please fill out the form below. We will contact you shortly.

If you are already a service recipient, and wish to request a service click here.

Name

First Name

Last Name

Address

Phone

(###)

###

####

Emergency Contact

Emergency Contact Phone

(###)

###

####

Emergency Contact Email

Let us know the services you may need help with (check all that apply)

Errands — e.g. grocery shopping, pharmacy, post office

Food – eg: meal prep, delivery

In Home Support — e.g., minor maintenance, organizing, cleaning, laundry

Outdoor Support — gardening tasks, snow removal

Social Engagement —e.g. home visits, telephone check-ins

Telephone Checkins — weekly or monthly calls to help with loneliness

Transportation/Escort — e.g. medical appointments; shopping

Other

If there is anything else you would like us to know about you, please share it here.

We value your privacy and do not share information. Read our privacy statement for more info.