Older Adults || Create Circles COVID-19 Form
Please reach out at
if you have any questions.
The email address below should be for the point of contact.
Name of Older Adult
Reside in long-term care community?
If yes, which one?
This information allows us to better communicate.
Which languages do you speak? (our volunteers know over 20 different languages)
What is the chat platform of choice?
Include any numbers/usernames/etc for the chat platforms.
Note: If you are filling this form out for multiple people, please pay attention to the time slots and number of devices that may be used at a certain time. We have discovered that visits before lunch often work the best. Please contact
if you would like assistance in determining your community's logistics.
How often would you like to speak with a volunteer?
Two times a week
Three times a week
Time Preference for Visit
Visits will be 30 minutes - 1 hour.
Monday, 9 AM - 11 AM
Monday, 11 AM - 1 PM
Monday, 1 PM - 3 PM
Monday, 3 PM - 5 PM
Tuesday, 9 AM - 11 AM
Tuesday, 11 AM - 1 PM
Tuesday, 1 PM - 3 PM
Tuesday, 3 PM - 5 PM
Wednesday, 9 AM - 11 AM
Wednesday, 11 AM - 1PM
Wednesday, 1 PM - 3 PM
Wednesday, 3 PM - 5 PM
Thursday, 9 AM - 11 AM
Thursday, 11 AM - 1 PM
Thursday, 1 PM - 3 PM
Thursday, 3 PM - 5 PM
Friday, 9 AM - 11 AM
Friday, 11 AM - 1 PM
Friday, 1 PM - 3 PM
Friday, 3 PM - 5 PM
Saturday, 9 AM - 11 AM
Saturday, 11 AM - 1 PM
Saturday, 1 PM - 3 PM
Saturday, 3 PM - 5 PM
Sunday, 9 AM - 11 AM
Sunday, 11 AM - 1 PM
Sunday, 1 PM - 3 PM
Sunday, 3 PM - 5 PM
By signing below, the resident provides written or verbal consent for volunteers to know their name, make virtual visits, and all other terms included in the document below. This consent may be provided to a family member, caregiver, or Activities Director.
Name of Point of Contact or Emergency Contact
This section is to be filled out by the point of contact. It may be the older adult themselves or someone at the long-term care facility. This person will receive all information about the visits and will be responsible for assisting us to make the visit possible.
Email of Point of Contact or Emergency Contact
Phone Number of Point of Contact or Emergency Contact
A copy of your responses will be emailed to the address you provided.
Never submit passwords through Google Forms.
This form was created inside of Harsh Moolani.