Creative Care Kit Program Signup
Creative Care Kit Sign-Up Form for the upcoming program year for new and previous year participants. If you need any assistance completing this form, please contact Caitlin Roseen, Director of Community Engagement, at croseen@cvcoa.org or 802-595-6971.
Name:
*
First Name
Last Name
Email:
example@example.com
Delivery Address for Kit and Binder:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
*
Please enter a valid phone number.
Date of Birth
*
-
Month
-
Day
Year
Date
What is your gender identity?
*
Male
Female
Non-binary
Transgender
Intersex
Prefer Not to Say
Other
Race
*
Please Select
American Indian/Native Alaskan
Asian
Black/African American
Native Hawaiian/Other Pacific Islander
Not Available
White
Ethnicity
*
Please Select
Hispanic or Latino
Missing/Unknown
Not Hispanic or Latino
What is your monthly household income (all sources)?
Above $1,132
Below $1,132
Declined to Answer
If filling out this form for someone else, please provide your name and best contact (phone or email):
Creative Activity Choice
Use this section to choose your Creative Care Kit activity. CVCOA will make every effort to provide kit recipients with their activity of choice. Since supplies might be limited, indicating your interest in future activities and your willingness to try any activity will be helpful.
Which of the following best describes you:
*
I am a new participant and need a Creative Care Kit.
I am a returning participant and want to continue using the supplies and materials I previously received.
I am a returning participant and just need a few supplies to supplement a kit I received previously (new activity binder provided if needed as well).
I am a returning participant and want to receive a new Creative Care Kit.
For returning participants who need supplemental supplies instead of a new kit, please list which supplies you need:
Which Creative Care Kit and activity binder would you like to receive?
Watercolor Painting
Drawing, Illustration, and Cartooning
Poetry Writing
Crafting (Rock Painting and Collage)
Digital Drawing with Sketchbook App
I can't decide - help me choose!
Which of the following additional opportunities are you interested in? (Choose as many as you wish - these are subject to funding and teaching artist availability.)
I would like to participate in group Zoom video calls with the Teaching Artists and other participants to share our work and discuss the creative process.
I would like to participate in the Creative Aging Celebration art show next spring to share my work with the community (details to be determined).
I would like to receive additional video lessons related to the activities in my kit.
I would like to receive an in-person visit from a teaching artist in my home.
Are there other artistic modes or creative activities you hope to engage in this year or in future years?
In 1-3 sentences, what is motivating you to engage in the creative process?
*
Creative Companion Preferences
Use this section to choose your preferences for connecting with others through creativity. CVCOA will make every effort to connect kit recipients with a Creative Companion volunteer. However, connections will be dependent on the number of participating volunteers and schedules of both parties. CVCOA cannot guarantee volunteers matches for all kit recipients.
Which of the following Creative Companion options are you interested in? (Choose as many as you wish.)
*
I would like to be connected with a Creative Companion volunteer who will contact me a few times per month to check in and discuss the creative activities with me.
I am already serving or would like to serve as a volunteer Creative Companion.
I prefer to complete the Creative Care Kit activity by myself and share my work with friends and family.
If you would like to be connected with a Creative Companion volunteer or you are serving as a volunteer, what is the best day of the week and time of day (in general) for your volunteer to connect with you?
In what ways would you prefer to connect? (Check as many as you wish. In person visits will be required to wear masks initially.):
Phone
Zoom or other video calling
In person
Do you have a preference for gender of your connection?
Female
Male
No preference
Other
Access to Technology
As part of the Creative Care Kits, CVCOA is offering a 6-month iPad device on loan, internet connection options counseling, and technology skills training to kit recipients who need help acquiring or using a device. CVCOA cannot guarantee availability of devices for all kit recipients who request one because technology will be offered to kit recipients on a first come, first served and highest-need basis. At the end of the 6-month iPad lending period, participants can apply to keep the iPad (application based on financial situation, usage, and motivation). You will receive a check-in call near the end of the 6 months to determine your ability to keep the iPad.
Would you like to receive an iPad as part of your Creative Care Kit?
*
Yes
Yes, I need more information about eligibility
Maybe, I need more information
No, I have an iPad from last year and just need training
No
Do you have access to an internet connection in your home?
Yes
No
I'm not sure
Would you like to receive more information about affordable internet options?
Yes
No
Please indicate your current comfortability / skill level with technology devices:
No Experience - I need help turning on the device and understanding basic functions.
Basic - I can perform basic tasks but need additional practice.
Proficient - I need help with more advanced features like adjusting settings, sharing photos, downloading and organizing apps, etc.
Advanced - I am comfortable using the iPad, but may be interested in advanced training topics.
Do you have a friend or family member who would also be willing to help you practice technology skills?
Yes
No
Maybe
Please describe any specific goals you have for how you would like to use technology (e.g. attending a wellness class, communicating with your Creative Companion volunteer, connecting with friends and family on social media, using Zoom to participate in community events):
Final Questions
How did you hear about the Creative Care Kit opportunity?(Choose the most relevant option if more than one applies.)
Received sign-up notice as a previous Creative Care Kit recipient
Meals on Wheels or local senior center
Referral from friend or family member
CVCOA Family Caregiver Program
CVCOA Case Manager or I&A
Community Arts Organization
Other
Are you interested in participating in a research project to help improve this opportunity and help others learn more about the impact of creative engagement on a variety of health factors?
Yes
No
Maybe, tell me more
Would you like to receive a call from a CVCOA Options Counselor to discuss additional services like caregiver support, transportation, housing, in-home supports, public benefits, nutrition and food access options, etc.? (If 'Yes,' you will receive a call from the CVCOA Helpline team.)
Yes
No
Please add any questions or comments here:
In order to facilitate kit delivery and volunteer connections, CVCOA needs to share contact information like phone numbers, email addresses, and delivery addresses. All CVCOA volunteers complete an onboarding process which includes background checks. Please sign in the box below to give CVCOA permission to share contact information between volunteers and kit recipients.
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