Neighbor Application Form
Thank you for your interest in becoming a neighbor! > Return to Homepage
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 TWO individuals we should notify.

Family

Select to use your family contact as your emergency contact.

Acknowledgement - Please read and provide your signature below

In completing this application, I agree to abide by Interlakes Community Caregivers’, Inc (ICCI) policies and guidelines, as may be adopted or amended from time to time. 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 Community Caregivers, 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.
Almost there! Don't forget to click the SUBMIT button! If you need help signing your name online, please call 603-253-9275 or email us at [email protected] for assistance.