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Chatting to Wellness - Phone Chat - Register Someone Else
This form is for someone to sign up another person for an Online Chatting Session (son/daughter registering mother/father, etc.)
Please complete all forms to register for Online Chatting Sessions. The first section is for you, the person registering for a senior, and the second section is information about the senior.
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* Indicates required question
Your Name
*
Your answer
Your Address
*
Your answer
Your Email
*
Your answer
Your Phone Number
*
Your answer
Seniors Name
*
Your answer
Senior's Age
*
Your answer
Senior's Address
*
Your answer
Senior's Email
Your answer
Senior's Phone Number
*
Your answer
What day(s) are you available for a call? (Calls are between 6pm-9pm)
*
Monday Night
Tuesday Night
Wednesday Night
Thursday Night
Friday Night
Required
I agree to the terms and conditions of Online Chatting Sessions and for communications (Found here:
https://bit.ly/3e3pCHJ
)
*
Yes
No
[OPTIONAL] Additional Comments (language, hard of hearing, extension number, etc.)
Your answer
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