First and Last Name of Legacy Holder
Provide an email address if you have one, or N/A:
Provide a phone number of Legacy Holder:
Any favorite hobbies or activities? (reading, music, etc.)
List some things that are important to Legacy Holder: (religion, family, etc.)
Who would you like to meet with you?
How would you like to communicate with your Legacy Builder?
Preferred days/times for interactions:
How did you hear about us?
( X )
Weekly Sessions & Legacy Book
Our Legacy Builder will meet weekly for one hour sessions, and with a minimum of 5 week sessions, a legacy book can be delivered.
Tellegacy Program Agreement
By selecting the "I Accept" button, the family/friend point of contact, or older adult (legacyholder) is agreeing to (on behalf of) participate in a trial of the TellegacyProgram. You will be matched with a college student (Legacy Builder) who willcontact you at designated times via telephone or virtual visit, as agreed uponahead of time. The intent of the calls/virtual visits are to makeintergenerational connections and to allow the legacy holder to share storieswith the Legacy Builder. The Legacy Builders are not trained counselors orprofessionals and the sessions do not constitute as mental health counseling.The goal of the program is to help combat loneliness and social isolation andinstill a sense of hope and purpose. The recipient has the right to Opt Out ofthe Tellegacy Program at any time by notifying the contact at their facility,Point of Contact family member, Legacy Builder, and/or Tellegacy team. Each legacyholder will be treated with dignity, respect and kindness during the Programand will report any concerns to the program lead immediately. Legacy holderagrees to treat the Legacy Builder with dignity, kindness and respect as well.The legacy holder agrees to share their weekly or monthly goals, and their pastlife experiences with the Legacy Builder. The Legacy Builder agrees to respectand honor the life experiences of the legacy holder. Legacy holder agrees thata Legacy Book can be created and given to the legacy holder as a summary of thediscussions at the end of at least 5 sessions. Legacy holder acknowledges that phonecalls/virtual visits can be recorded for training and quality purposes.
By selecting the "I Accept" button, you are signing this Agreement electronically.
I Do Not Accept
Do you agree to allow the use of photos and/or videos taken for training, promotion or publicity purposes for the Tellegacy Program?
Should be Empty:
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