RCSS Registry Member

As a RCSS Registry Member, the Renfrew-Collingwood Seniors’ Society will call you during an emergency to check in and assess if you require any additional support. Our centre may be open for relief services from extreme weather including the heat wave. Details of opening hours will be provided to you in advance. Complete the form below or if you prefer a printed version, please download one of the forms: 

Registry Member Form_Chinese Version
Registry Member Form_English Version

Completed forms can be dropped off in-person, mailed or emailed to us at cly@rencollseniors.ca. Your information will be kept confidential. For more information, please take a look at our “Emergency Support for Seniors Framework.” We welcome your suggestions and feedback!

Name *

First

Last

Phone Number *

Email

Gender

Pronouns

• she/her
• he/him
• they/them

Home Address *

If we need to call Emergency Health Services on your behalf, we will need to inform them about where you live. Please include your postal code and information on how to access your suite or house including room number, buzzer code and whether your front or back entrance/alleyway is the best way to get in.

Do you have any pets?

Preferred Language(s)

Dietary Restrictions & Allergies

Do you use a cane, walker or wheelchair?

Do you receive any Home Support services? If YES, how often?

Personal Health Information - Is there anything you would like us to know about your health condition(s)?

Primary Emergency Contact (Living closest to you) *

Please include their name, relationship to you, phone number, and email address.

Secondary Emergency Contact

Please include their name, relationship to you, phone number, and email address.

Out-of-Town Emergency Contact

Please include their name, relationship to you, phone number, and email address.

Submit