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Caregivers in the Hills – ID Badge Online Application

The benefits of applying for a Caregivers in the Hills identification badge

  • You will be recognized as a Caregiver by healthcare providers in the Hills of Headwaters Collaborative
  • It will give you confidence to ask questions to support your loved one
  • Providers will recognize you as a caregiver and it will provide validation of your role and presence in the healthcare setting
  • Facilitates you as a partner in care

Caregivers in the Hills - ID Badge Online Application

Please fill out this application form for the Caregivers in the Hills program. To successfully complete, you will need to have a photo of yourself prepared to upload for your Caregiver Identification Badge. This application may also be filled out over the phone. If you would prefer to do so, please call Caregivers in the Hills at 519-216-6671. We are currently accepting applications from unpaid caregivers who reside in Dufferin County or Caledon, or care for someone who does. All fields marked with an asterisk (*) are required.

(Ms., Mr., Mrs., Dr.)
Name(Required)
Address(Required)
I provide unpaid care for someone who lives in Dufferin County or Caledon, and needs help due to disability or ill health. This includes caring for a family member, loved one or friend.(Required)
I provide care for an adult.(Required)
I care for multiple people.(Required)
I consent to my personal information being collected and stored under the Hills of Headwaters Collaborative secure database.(Required)
Max. file size: 1 GB.
· Please provide a passport-style photo (smiling allowed and encouraged).
· Your photo must reflect your current appearance.
· Your face must be fully and clearly visible (no sunglasses or hats).
· Your photo must be centered and taken straight on, with centred and squared to the camera.
· Your photo must have uniform lighting and not show shadows, glare or flash reflections.
· Your photo must be clear, sharp and in focus.
· Your photo must be in colour.
· Your photo must not be digitally altered (cropping and resizing is acceptable).
· File should be sent to us with FirstName-LastName.jpg
· Minimum resolution 200 X 230, 96 DPI
Do you need help uploading your photo?
Name of the person you care for.(Required)
Please give a response in years and months. (ex: 4 years, 8 months)
Please give a detailed summary of the care you provide to your loved one(s).
Please tick all that apply.
Signed(Required)
MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.

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We acknowledge that Hills of Headwaters Collaborative Ontario Health Team and its partners work within the traditional territories and ancestral lands of the Tionontati (Petun), Attawandaron (Neutral), Haudenosaunee (Six Nations) and Anishinaabe peoples.

Hills of Headwaters Collaborative Ontario Health Team is supported by funding from the Government of Ontario.

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