Homebound Seniors Form

Please complete this form to help keep the Town notified of Homebound Seniors in our community so we may better serve them.

form.antibot { display: none !important; } You must have JavaScript enabled to use this form.

First Name *

Last Name *

Birth Date

edit-submitted-birth-date-month

edit-submitted-birth-date-day

edit-submitted-birth-date-year

Street Address *

Phone Number *

Email Address *

A contact email for the senior or for the person completing this form.

Emergency Contact Person *

Emergency Contact Phone Number *

Is the senior frail or disabled? Please check all that apply. *

Frail

Disabled

None

Contact Information

Site Manager
Noreen O'Driscoll

Phone: (914) 962-7447
Fax: (914) 962-3260
[email protected]

Albert A. Capellini Community & Cultural Center
1974 Commerce Street
Yorktown Heights, NY 10598
Click Here for Directions

Hours: Monday - Friday
9:00 a.m. to 2:30 p.m.

Home Meal Delivery:
Available Weekdays