Online Forms

2. 
4. Seniors’ Isolation Survey
   We want your input! As a member of the Hinton community over age 55, how are you affected by isolation and what services in our community would make you feel more connected?
6. 1. Are you over the age of 55?

   1. Yes
   2. No
   3. Prefer not to answer
8. 2. Do you experience being lonely, disconnected, or socially isolated?

   1. Yes
   2. No
   3. Prefer not to answer
10. 3. What activities or events would you like to see in Hinton to feel connected to the community?
12. 4. Even as an older adult we are always learning new things. What are some examples of new things are you interested in learning about (for example, technology or exercise)?
14. 5. Would you be interested in receiving a regular Seniors Newsletter?

    1. Yes
    2. No

    If yes, please provide contact information below.
16. 6. Would you be interested in being on a planning committee for seniors events and activities?

    1. Yes
    2. No

    If yes, please provide contact information below.
18. First Name
19. Last Name
21. Email Address
22. Phone Number
24. 4. Additional Comments
    (please add any additional feedback here)
26. Thank You!
    Your input is appreciated. If you would like more information, please contact Randy at 780-865-6023 or rsmith@hinton.ca
Leave This Blank:


28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit

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