Registration

Welcome to the registration page for our Seniors Assistance program

Please fill out the form accurately and clearly to register for our Seniors Assistance program.

Full name

Last Name

Current Age:

Home Address:

Email address

Phone Number:

Are you currently employed?

If yes, where?

Are you currently receiving pension?

What is your total monthly income?What is the total of your monthly expenses?

Are you interested in taking a course?

Are you raising any of your (great) grandchildren? If yes, how many?

If yes, how many?

What are their ages?

Do their parents provide support?

If yes, how much?

Do their parents live on the island?

Do you always have enough to eat?

How would you rate your current living situation?Are you in need of eyeglasses?Are you in need of dentures?Are you in need of getting your teeth cleaned?

When was your last visit to a dental clinic?Do you have any ailments or illnesses?

If yes, what are they?

What do you do for recreation and companionship?

How did you hear about us?

Once you register and are accepted into the program you will have to commit to it. We will contact you to meet with you personally and may ask you to verify of some of the information mentioned above. After meeting with you, our team will make a final decision and contact you about our selection. Your information will be kept confidential and not shared with any third parties.

Please know, that Kingdom Courtyard is a safe space for your healing and support.

Thank you! Your submission has been received!

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