Contact Information
Please complete this Contact Information section with the details of the primary contact person. The individual listed in this section will be contacted by our Marketing Department.
Please Contact Me By:
First Name*
Last Name*
Street Address
Suite/Unit #
Phone Number*
Applicant Information
The details listed in this section pertain to the individual(s) seeking Retirement, Respite or Assisted-Living accommodation.
For whom are you seeking housing or care services?*
If other than self, what is the Applicant's name?
What is this person's age?
With which tasks of daily living, if any, does this person need help?*

Does the applicant currently receive any care-related services?*

How mobile is this person?*

Describe any health conditions this person may have:
How soon does the applicant needs accomodation?*
Tell us where you first heard about Shepherd Village:*
If other, please specify:
By clicking on the 'Submit' button below I confirm that the information contained in the form above is accurate and true. I agree that my information will be added to a contact list and permit Shepherd Village to contact me via phone, email or CanadaPost for an offer of accommodation or for various other Shepherd Village purposes. I understand that my information will be kept secure and confidential and be used for Shepherd Village purposes only. You will be redirected to a confirmation page.