{"id":40,"date":"2023-07-08T00:05:03","date_gmt":"2023-07-08T00:05:03","guid":{"rendered":"https:\/\/ucspcanada.org\/ucmain\/?page_id=40"},"modified":"2023-07-08T02:32:41","modified_gmt":"2023-07-08T02:32:41","slug":"senior-registration","status":"publish","type":"page","link":"https:\/\/ucspcanada.org\/ucmain\/senior-registration\/","title":{"rendered":"Senior Registration"},"content":{"rendered":"\n<p><strong>United Community Services of Peel (UCSP)<\/strong> is committed to helping the seniors according to its capacity. Please fill the form and one of our volunteers will contact you.<\/p>\n\n\n\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f44-o1\" lang=\"en-US\" dir=\"ltr\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/ucmain\/wp-json\/wp\/v2\/pages\/40#wpcf7-f44-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"44\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.8.6\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f44-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/div>\n<div class=\"justify-content-center h-100\">\n\t<div class=\"card\">\n\t\t<div class=\"card-header\">\n\t\t\t<h3> Senior Registeration\n\t\t\t<\/h3>\n\t\t<\/div>\n\t\t<div class=\"card-body\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"sen-first-name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" id=\"sen-first-name\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"First Name\" value=\"\" type=\"text\" name=\"sen-first-name\" \/><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sen-last-name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" id=\"sen-last-name\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Last Name\" value=\"\" type=\"text\" name=\"sen-last-name\" \/><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sen-gender\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required form-control\" id=\"sen-gender\" aria-required=\"true\" aria-invalid=\"false\" name=\"sen-gender\"><option value=\"Male\">Male<\/option><option value=\"Female\">Female<\/option><option value=\"Other\">Other<\/option><option value=\"Prefer not to disclose\">Prefer not to disclose<\/option><\/select><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sen-age\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" id=\"sen-age\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Age\" value=\"\" type=\"text\" name=\"sen-age\" \/><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sen-address\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" id=\"sen-addresss\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Address\" value=\"\" type=\"text\" name=\"sen-address\" \/><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sen-city\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" id=\"sen-city\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"City\" value=\"\" type=\"text\" name=\"sen-city\" \/><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sen-province\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" id=\"sen_province\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Province\" value=\"\" type=\"text\" name=\"sen-province\" \/><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sen-postalcode\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" id=\"sen_postalcode\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Postal Code\" value=\"\" type=\"text\" name=\"sen-postalcode\" \/><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sen-home-phone\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel form-control\" id=\"sen-home-phone\" aria-invalid=\"false\" placeholder=\"Home Phone\" value=\"\" type=\"tel\" name=\"sen-home-phone\" \/><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sen-mobile-phone\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel form-control\" id=\"sen-mobile-phone\" aria-invalid=\"false\" placeholder=\"Mobile Phone\" value=\"\" type=\"tel\" name=\"sen-mobile-phone\" \/><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sen-email\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email form-control\" id=\"sen-email\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Contact Email\" value=\"\" type=\"email\" name=\"sen-email\" \/><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sen-nok-name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" id=\"sen-nok-name\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Next of Kin (NOK) Name\" value=\"\" type=\"text\" name=\"sen-nok-name\" \/><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sen-nok-relation\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" id=\"sen-nok-relation\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"NOK Relation\" value=\"\" type=\"text\" name=\"sen-nok-relation\" \/><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sen-nok-phone\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" id=\"sen-nok-phone\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"NOK Phone Number\" value=\"\" type=\"text\" name=\"sen-nok-phone\" \/><\/span>\n\t\t\t<\/p>\n\t\t\t<p> I require assistance as follows:\n\t\t\t<\/p>\n\t\t\t<string>Manage Loneliness:\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"sen-support\"><span class=\"wpcf7-form-control wpcf7-checkbox form-control\" id=\"sen-support\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"sen-support[]\" value=\"Social Gatherings\" \/><span class=\"wpcf7-list-item-label\">Social Gatherings<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"sen-support[]\" value=\"Companionship\" \/><span class=\"wpcf7-list-item-label\">Companionship<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"sen-support[]\" value=\"Telephone Conversation\" \/><span class=\"wpcf7-list-item-label\">Telephone Conversation<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<p><br \/>\n<strong>Mobility Support for daily tasks:<\/strong><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sen-support-tasks\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text form-control\" id=\"sen-support-tasks\" aria-invalid=\"false\" placeholder=\"Specify details\" value=\"\" type=\"text\" name=\"sen-support-tasks\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<p><br \/>\n<strong>Transportation:<\/strong><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sen-support-trans\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text form-control\" id=\"sen-support-trans\" aria-invalid=\"false\" placeholder=\"Specify details\" value=\"\" type=\"text\" name=\"sen-support-trans\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<p><br \/>\n<strong>Other:<\/strong><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sen-support-oth\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text form-control\" id=\"sen-support-oth\" aria-invalid=\"false\" placeholder=\"Specify details\" value=\"\" type=\"text\" name=\"sen-support-oth\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/string>\n\t\t<\/div>\n\t\t<div class=\"card-footer\">\n\t\t\t<div class=\"text-left\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"sen-acceptance\"><span class=\"wpcf7-form-control wpcf7-acceptance\"><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"sen-acceptance\" value=\"1\" id=\"sen-acceptance\" aria-invalid=\"false\" \/><span class=\"wpcf7-list-item-label\">Please click checkbox to accept Liability Waiver Disclaimer.<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"text-right\">\n\t\t\t\t<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" id=\"send\" type=\"submit\" value=\"Register\" \/>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n<\/div><p style=\"display: none !important;\" class=\"akismet-fields-container\" data-prefix=\"_wpcf7_ak_\"><label>&#916;<textarea name=\"_wpcf7_ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_1\" name=\"_wpcf7_ak_js\" value=\"16\"\/><script>document.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );<\/script><\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n\n\n\n\n<p>Please click here to view <a rel=\"noreferrer noopener\" href=\"https:\/\/ucspcanada.org\/ucmain\/liability-waiver-disclaimer\/\" data-type=\"page\" data-id=\"61\" target=\"_blank\">Liability Waiver-Disclaimer.<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"<p>United Community Services of Peel (UCSP) is committed to helping the seniors according to its capacity. Please fill the form and one of our volunteers will contact you. Please click here to view Liability Waiver-Disclaimer.<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-40","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/ucspcanada.org\/ucmain\/wp-json\/wp\/v2\/pages\/40","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/ucspcanada.org\/ucmain\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/ucspcanada.org\/ucmain\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/ucspcanada.org\/ucmain\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/ucspcanada.org\/ucmain\/wp-json\/wp\/v2\/comments?post=40"}],"version-history":[{"count":10,"href":"https:\/\/ucspcanada.org\/ucmain\/wp-json\/wp\/v2\/pages\/40\/revisions"}],"predecessor-version":[{"id":95,"href":"https:\/\/ucspcanada.org\/ucmain\/wp-json\/wp\/v2\/pages\/40\/revisions\/95"}],"wp:attachment":[{"href":"https:\/\/ucspcanada.org\/ucmain\/wp-json\/wp\/v2\/media?parent=40"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}