Kootenay Virtual Caregiver Café

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* 1. Are you Caregiving for a Senior in the Columbia Basin?

Yes

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* 2. Which Community do you live in?

Cranbrook

Kimberley

Fernie

Invermere

Radium Hot Springs

Golden

Sparwood

Elkford

Creston

Nelson

Castlegar

Revelstoke

Nakusp

Salmo

Fruitvale

Silverton

Other (please specify)

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* 3. I am a Caregiver to:

My Spouse

My Parent/s

My sibling

My Neighbor

My Friend

Other (please specify)

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* 4. As a Caregiver, I support this person in:

My home

Their home (we live separately in the same Community)

Long distance (they live outside of my Community)

Long Term Care

Assisted Living

Other (please specify)

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* 5. I am aware of the services that the Caregivers Network provides

Definitely

Somewhat

Not aware

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 6. I would like to participate in a virtual caregiver support group twice a month

Yes

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* 7. I have the technology and internet capability to participate in Zoom

Yes, I have both and am ready to start!

I have both but am not sure where to start

I don't have a device, but have internet

I wouldn't know where to begin

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* 8. I would prefer a meeting:

In the morning

Over the noon lunch hour

In the afternoon

In the evening

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* 9. If you would like to receive information about our new Caregiver Cafe Meetings, please complete the following information. Your information will not be shared with anyone and will remain confidential.

Name

Address

City/Town

Province

Postal Code

Email Address

Phone Number

Kootenay Virtual Caregiver Café

Question Title

* 1. Are you Caregiving for a Senior in the Columbia Basin?

Question Title

* 2. Which Community do you live in?

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* 3. I am a Caregiver to:

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* 4. As a Caregiver, I support this person in:

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* 5. I am aware of the services that the Caregivers Network provides

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* 6. I would like to participate in a virtual caregiver support group twice a month

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* 7. I have the technology and internet capability to participate in Zoom

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* 8. I would prefer a meeting:

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* 9. If you would like to receive information about our new Caregiver Cafe Meetings, please complete the following information. Your information will not be shared with anyone and will remain confidential.

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* 10. If you would like to share any information, please do so now.