Kensington Club@Home Application for Club Applicant
Care Partner Name
First Name
Last Name
Name of Club Applicant
First Name
Last Name
Club Applicant Email
example@example.com
Applicant Address (if different from Care Partner)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Best Phone Number for Applicant
-
Area Code
Phone Number
Cell Phone Number if Different
-
Area Code
Phone Number
Do you have a diagnosis?
Yes
No
If Yes, what year?
What do you hope to gain from Kensington Club@Home?
I want to do something fun and learn new things.
I want to meet others who are facing the same challenges and make new friendships.
I want to be proactive about my diagnosis and do something about it.
Emergency Contact other than Care Partner
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Phone
-
Area Code
Phone Number
Submit
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