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Neighbor Application Form
Thank you for your interest in becoming a neighbor!
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e.g., Alone, With Family, 50+ Community, Nursing Home
Please select all that apply

Emergency Contact

In the event of an emergency, please let us know whom we should notify.

Family Contact

Acknowledgement - Please read and provide your signature below

In completing this application, I confirm that all information is correct to the best of my knowledge. I also acknowledge that services will be provided by volunteers in response to each individual service I request. I give my permission for a member of Interlakes CommunityCaregivers, Inc. to confirm my appointment with a service provider, if necessary. My signature will be kept on record by ICCI and will apply to all services provided. I understand that ICCI will keep all information I provide confidential.
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