Older Adult Home Safety Program

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Applicant Information

Is this application a referral on behalf of another? * Yes No

Recipient Name (First, Last) *

Date of Birth (dd/mm/yyyy) *

Street Number *

Street Name *

Street Type *

Town/City *

Unit Number

Postal Code

Telephone Number *

Email Address

How did you hear about the program? *

Town of Caledon Website

Social Media

Town eNewsletter

Weekly Local Newspaper

Age-Friendly Caledon eNewsletter or Outreach

Community Agency

Word of Mouth

Other

Home Information

Does the home currently have Smoke Alarms? * Yes No

What type of alarms do you have? * Battery Hard-wired Combination Unknown

Does the home currently have Carbon Monoxide (CO) Alarms? * Yes No

Please identify the type of dwelling for this application? *

Single Storey / Bungalow

Multiple Storey (2+ floors)

Condo

Apartment

Other

Please provide the estimated age of the home. *

New Build (less than 1 year old)

1-10 years old

10-20 years old

20+ years old

Other

Date of Construction (dd/mm/yyyy)

First and Last Name (this will be your signature) *

Privacy * I understand and acknowledge that personal information contained on this form is collected under the authority of Section 365 of the Municipal Act, SO 2001, and will be used only for the purpose of administrating the Older Adult Home Safety Program. Questions about this collection should be directed to the Municipal Freedom of Information Coordinator, Town of Caledon, 6311 Old Church Road, Caledon, Ontario, L7C 1J6, 905.584.2272.