Home Seniors Sign Up Form (Database Tracking) Seniors Sign Up Form (Database Tracking)Baobab Black Seniors Health and Social Care Services Society – Seniors Sign Up FormCelebrating culture, connection, and community.No Black Senior in BC Left Behind.We see you. We hear you. We honor you.Full NamePreferred NameAge Range 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90+Gender (optional)- Select -FemaleMaleNon-binaryPrefer not to sayCity / TownRegion (in BC)- Select -Lower MainlandVancouver IslandInteriorNorthern BCOtherEnter your Region (in BC)Phone NumberEmailCountry of Origin / HeritageSelect CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelauBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDemocratic Republic of the Congo (Kinshasa)DenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of the Congo (Brazzaville)ReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabweLanguages SpokenWhich cultural or ethnic group do you identify with? (Select all that apply) African Afro-Caribbean African American Afro-Latino Black Mixed heritage In your own wordsWhich cultural or ethnic group do you identify with?Are there cultural activities or traditions you would like to see included in our programs?How would you like to be involved? (Select all that apply)Join Baobab’s Senior Support NetworkVolunteer with Baobab Black SeniorsGet support services or resourcesAttend senior events and activitiesConnect with other Black seniors in my communityAdvocate for Black seniors in BC as a representative on the Elders CouncilIn your own words(please specify)In your own words (please specify would you like to be involved?)If you checked “support services or resources,” please describe what kind of support you are looking for (Select all that apply)Health and WellnessHousing and Living SupportFinancial and Legal SupportSocial ServicesAdvocacy and LeadershipCaregiver and Family SupportTechnology and Digital AccessTransportation and MobilityEducation and Lifelong LearningCultural and Heritage ProgramsSpiritual and Faith-Based SupportFood Security and Nutrition SupportRecreation, Community Life and general Volunteer opportunitiesConsent & PrivacyBy signing below, I consent to Baobab Black Seniors collecting and using my personal information for the purpose of program coordination, communication, and safety. My information will be kept confidential and will not be shared without my permission.Initials (to show consent):Date:Sign Up
