Organization Information

* Required Fields

Organization Name

*Required

Website

*Required

CRA Number (if applicable include your 9 digit number below ie. 123456789 RR0001).

Mailing Address

*Required

City

*Required

Province

*Required

Postal Code

*Required

Organization Phone Number

*Required

Organization Email

*Required Your entry is not a valid email address!

Contact First Name

*Required

Contact Last Name

*Required

Our organization is a:

*Required

Other (please specify):

What is the annual operating budget of your organization?

Seniors are:

*Required

How many seniors do you serve annually?

*Required

What is your organization's mission? Please provide a 200 word description of your organization.

Digital Assessment

What are the greatest challenges for seniors in your community? Check all that apply.

Not able to talk to their family members

Inability to perform basic activities safely like grocery shopping, medication retrieval, banking, etc.

Barriers to accessing government support

Inability to receive medical support

Lack of emotional and mental engagement and/or stimulation

Have you experienced any barriers to date in attempt to introduce technology in your community?

*Required

If yes, please explain.

Responsibilities and Program Fit

We understand that this program is for low-income seniors and will solicit participants accordingly.

We understand our responsibility to identify volunteers to participate in this program.

How will the tablets and support services help seniors avoid isolation and engage more fully in their community?

We will need to work closely with your staff in the initial phases of the program. Please provide the information below for the designated personnel (staff or volunteer) for this program.

Name

*Required

Phone Number

*Required

*Required Your entry is not a valid email address!

Please provide the designated personnel’s title and describe their role:

Please indicate the best availability of the designated personnel managing this program so that they can be contacted if necessary.

*Required

Please add any clarifications and preferences around the availability provided.

Is the mailing address provided above the best place to ship the tablets?

*Required

If no, please provide the shipping address below:

Approximately how many participants do you foresee taking part in the program? This number will be confirmed upon grant approval.

*Required

We confirm that we will be able to start this program within the next 6-8 weeks.

We have read and understood the program description and our requirements if accepted into the program.

We have the capacity to enroll participants and volunteers within 4 weeks following approval.

Privacy Policy
Personal information collected in this application by HelpAge Canada is treated in accordance with our Privacy Policy and will be used to complete a thorough assessment of your proposal. Information provided by grantees for the purpose of reporting, will not be shared outside our organisation without your explicit and informed consent.