Senior Interest Form

Senior Interest Form

We'll utilize the information you provide on this form to create a truly unique 'BOX' for your loved one.
Name
Sex
DOB
Birthplace
Marital Status
Spouse/Significant other
I have blanks children.
I have a total number of blank grand, great-grand, or great-great-grand children
Veteran
Branch & date

MonthDayYear
Date
Is spouse a veteran
Date of service

MonthDayYear
Date
Religious affiliation
Education level
Ability to read
Ability to write
Vision Impaired
Hearing Impaired
Memory Impaired
Past occupations & jobs
Organizational involvement
Interest Survey
Interest in Games
Check all that apply:

BingoCheckersChessBackgammonDominoesMonopolyScrabbleYahtzeeOther
Interest in Cards
Check all that apply:

BridgeCanastaGinPinochlePokerSolitaireOther
Interest in crafts
Check all that apply:

CrochetingDoll makingGlass blowingHooking rugsKnittingLeather workingNeedlepointPlastic craftScrap bookingStained glassWoodworkingEmbroideryQuilting
Interest in Exercise
Check all that apply:

AerobicsStretchingWalkingJoggingSwimming
Interest in gardening
Interest in outing
Interest in music
Interest in puzzles
Interest in sports
Interest in television
Interest in reading
Interest in sewing
Interest in movies
Interest in computers
Interest in pets
Interest in art
NOTES
Name of person completing form
Relationship
Date

MonthDayYear
Date
Should be Empty: