BSRI Housing Interest Form

BSRI Housing Interest Form
To best understand and assist with your senior housing needs, please fill out the following questions.
How did you hear about us?*

BSRI WebsiteCCALFacebookOther Social MediaThe Coastal Buzz MagazineFriend/ReferralBSRI Senior Center StaffOther
Name*

First NameLast Name
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.
Phone Number is:*

HomeCellWork
Gender*

MaleFemalePrefer not to answer

Current Address*

Street Address

Street Address Line 2

CityState

Zip Code
Number of Occupants? *
Pets?*

YesNo
Preferred Unit Type?*

ApartmentHouseRanch Style HomeOther
Bedrooms? *
Desired Move-in Date*

MonthDayYear
Date
Preferred Location (Select all that apply)*

CalabashSSBSupplySouthportShallotteOcean IsleOther
Monthly Rental Budget
Minimum*
Maximum*

What type of amenities and activities would you be most interested in?*

ClubhouseMealsOutdoor Grilling AreaFitness CenterDog ParkCraft/Library/Puzzle RoomExercise ClassesBilliards/Movies Theatre RoomOn-site Nurse/Medication AssistanceTrash Pick Up
What type of utilities would you be most interested in?*

Cleaning ServiceOutdoor PoolSubsidized AssistanceOther
Should be Empty: