Olive Live Learn Thrive Day Program Registration
Name
*
First Name
Last Name
Email
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
*
Please enter a valid phone number.
Date of Birth (Month-Day-Year)
*
Choose one or more races that you consider yourself to be:
*
White
African American
Hispanic
South Asian (eg. Indian, Pakistani, Bengali)
Other Asian
Arab
Other
Age Range
*
55-64
65-74
75-84
85+
Emergency Contact Name
*
Emergency Contact Number
*
Emergency Contact Relationship
*
Food Allergies
Other Food Preferences/ Dietary restrictions
Medical conditions we should be aware of:
Are you fully vaccinated for Covid 19? (Proof of vaccination is required for indoor in-person program attendance)
*
Yes
No
I have taken the booster as well.
Languages spoken
*
Do you have access to reliable transportation?
Yes
No
Which of the following do you have access to? (Choose all that apply)
Lap top
Smart phone
Tablet
Zoom app
Whats app
Facebook
Instagram
Youtube
None of the above
Hobbies/Interests
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Help Olive grow!
Which of the following Olive programs are you interested in?
*
Olive Live Learn Thrive (Day program)
Olive Online (Virtual programs via Zoom)
Olive Outdoors (Family Nature walks)
Olive Friend (Befriending homebound Olivers)
Olive Fit and Fun (Exercise, Wellness Challenge, Walkathon)
Olive Connect and Create (Arts, crafts, lifestyle, reading & writing)
Oliver Storytime (Sharing stories with the youth)
Olive Travel (Destination travel)
How would you like to volunteer for Olive? (Choose all that apply)
*
Be an Olive friend to another senior
Volunteer as Program Aide for day program
Be a part of a planning/project committee
Lead a session
Share your hobbies/interests
Volunteer at events
Share your life experiences with youth
Teach (languages, arts and crafts)
I am unable to volunteer at this time
Comments and suggestions
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Please review and sign the following waivers
Signature
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Thank you for completing this form, your officially an Oliver!
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