Client Application

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Please tell us how we can assist you by completing the form below.

Name

Street Address

City, State, Zip

Phone Number

Please tell us your birthday (month & day only)

Please List Your Age Bracket

Please list the names of anyone currently living with you and their relationship to you:

How did you hear about Urbandale Caring Corps?

What type of service are you requesting?

Type of Service Requested

Grocery Shopping
Transportation
Simple Handyman Job
Companionship
Yard Work

Grocery Shopping and Errands. Do you need

Would You Prefer to:

Go to Store with Volunteer
Send Volunteer to Store w/List

Do you tire easily while shopping and need assistance?

Yes
No

Do you need help carrying groceries in and putting them away?

Yes
No

Do you need assistance walking to the door?

Yes
No

Do you use any of the following?

Cane
Walker
Wheelchair

Can You Get In and Out of the Car with Minimal Assistance?

Yes
No

Are you able to get in and out of a Minivan or SUV?

Yes
No

What Type of Handyman Service Do You Need?

Companionship: Would you prefer:

Friendly Calls
Visits in the Home
Both

Check how often you'd like a volunteer to visit with you.

How Often Would You Like Visits?

One Hour a Week (Suggested)
Two Hours a Week
Other: Please Call 278-3999

Yard Work

Equipment. Do you have

Type in the estimated size of your yard.

What are the dimensions of your yard?

Is your yard:

level?sloped?

Is there anything our volunteers should be aware of while they are assisting you?

Submit

Thank you for sumitting this Service Request Form. One of our volunteers will contact you soon!

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