West Kootenay Boundary Caregiver Support » Social Meal Form Social Meal Form This form is intended for people who attend our social meals on a regular basis. Please contact your local program coordinator for more information.Date: (mm/dd/yy): *How did you find out about WKB Social Meals? *BC211UW Online DatabaseHost OrganizationHospicesCommunity-Based AgencyAdvertisementSocial WorkerNursePhysicianCase WorkerOther Allied health professionalFriend/FamilySelf-ReferralUnknownOtherFirst Name *Last Name *Date of Birth (mm/dd/yy) *Main Phone *Type of connection *Cell PhoneLand LineText Messsages? *YesNoVoicemail? *YesNoEmail *Street Address *Apartment, suite, etcCity *State/Province *ZIP / Postal Code *How do you identify? *MaleFemaleNon-binaryTransgenderOtherPrefer not to sayMarital status: *MarriedCommon lawSingleDivorcedWidowedPrefer not to discloseLiving Arrangements *Living aloneDo not live aloneUnknownPrefer not to discloseOtherLanguage(s) spoken *EnglishFrenchIndigenous language(s)RussianGermanSpanishTagalogMandarinCantoneseHindiFarsi/PersianJapaneseKoreanPortuguesePunjabiUkranianOtherEthnic Origin *Black (African, Caribbean descent)ArabChineseFilipinoIndigenous (First Nations, Metis, Inuit)JapaneseKoreanEast Asian (e.g. Chinese, Japanese, Korean)South Asian (East Indian, Pakistani, Sri Lankan)Southeast Asian (Vietnamese, Cambodian, Laotian, Thai)West Asian (Iranian, Afghan)Indigenous (First Nations, Metis, Inuit)Latin, Central, or South AmericanWhite (European descent)Do not knowPrefer not to discloseOtherDo you identify as a member of an underserved or equity deserving group?YesNoExamples might include: experiencing cultural and/or linguistic barriers; deaf and hard of hearing; experiencing elder abuse; experiencing mobility barriers; 2SLGBTQIA+; newcomers/ temporary residents; people with disabilities; permanent residents (immigrants and refugees); at risk of homelessness; at risk/experiencing mental health issues; at risk/experiencing physical health issues; other.To help us better understand the communities we serve and to ensure our services are inclusive and equitable, please select all that may apply.Single Person Income - Living alone *At or below $32290$32291 - $571999 Over $57200N/A (More than one person in household)Prefer not to discloseHousehold Income - 2 or more people in the home *At or below $49310$49311 - $107699Over $107700N/A (One person in the home)Prefer not to discloseHow often do you feel that you lack companionship? *Hardly everSome of the timeOftenPrefer not to discloseHow often do you feel left out? *Hardly everSome of the timeOftenPrefer not to discloseHow often do you feel isolated from others? *Hardly everSome of the timeOftenPrefer not to discloseComments:Once you submit the form a representative of the West Kootenay Boundary Caregivers Support will be in contact with you.Send Message
