Register a beneficiary

One of our coordinators

will get in touch with you in order to do the

appropriate follow-up.

We look forward to responding to your application

as quickly as possible

depending on the availability of our volunteers.

Form to register new beneficiaries to the service of spiritual accompaniment of Pastoral Home Care / SASMAD

Name*
First Name Last Name
Date of birth
Date of birth of the beneficiary
YYYY dash MM dash DD
Gender*
Choose if the person to be accompanied is male or female.
E-mail of the person filling out this form
Date of registration*
Date when the new registration was received or is being created (today's date)
YYYY dash MM dash DD
Living environment (At home/ Private Residence/ Public establishment) :
Addresse*
Postal Address line 1 Postal Address line 2 City Province Postal Code
Telephone 1*
Telephone 2
Parish
Please indicate the territory of the Parish where the beneficiary resides (optional)
Sector
(Laval/ Repentigny, Centre, East, West, Anglophone)
Spoken Languages :*
Please indicate all languages that the beneficiary are able to speak
Language for the accompaniment :*
Specify the language for the accompaniment
Health Status :
Reasons or needs :*
Please indicate all that are applicable
- I would like to talk to a priest
- I would like to receive the sacraments of Confession and Communion
- I would like to be visited by a volunteer and have somebody to talk to
- Other (please explain on the here below space)
Other reasons or needs :
Beneficiary referred by (Full name / Title or relationship / Telephone/ Specific Requests)
Family references (Full name / Relationship to the beneficiary / Telephone and other contacts if applicable)
Message or additional comments (optional) :
Thank you so much for your registration !

Thank you so much for your registration !