Friendly Visitors Senior Interest Form
Today's Date
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Month
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Day
Year
Date Picker Icon
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Hour
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10
20
30
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50
Minutes
AM
PM
AM/PM Option
Recipient's Full Name
First Name
Last Name
Name of person filling out form
Phone Number of person filling out form
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Area Code
Phone Number
Email of person filling out form
example@example.com
Recipient's Date of Birth
Recipient's Phone Number
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Area Code
Phone Number
Recipient's Email (if applicable)
example@example.com
Recipient's Home Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Recipient Preferences
Tell us what works for you!
Would you prefer:
Phone calls ONLY
Phone calls AND visits
Home visits ONLY
Does not matter
What is the best DAY of the week for a phone call or visit from your companion?
What information is important for us to know so we may make the best match?
What is the best TIME of day for a phone call or visit from your companion?
How long would you like your companion to visit with you?
10-15 minutes per week
30 minutes per week
1 hour per week
Does not matter to me
I would prefer my companion to be:
Male
Female
Does not matter
Tell us why you are interested in the Friendly Visitors program and what you would like get from your companion:
Submit
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