Client Enrollment Application

Allies in Aging, Senior Companion Program Client Enrollment Application

Please print and complete all sections. Please answer honestly to help ensure the best match with a volunteer.

Name

Birth Date

Date

Age

Mailing Address

City

State

Zip

Phone

Format: (000) 000-0000.

Cell Phone

Format: (000) 000-0000.

Email

example@example.com

Do you currently experience loneliness or feelings of isolation?

Do you currently experience sadness, depression, or hopelessness?

What is the main type of service you are seeking?

What is the biggest challenge you are currently facing that threatens your ability to stay in your home?

Do you require any special accommodation or have physical or medical considerations that may impact a volunteer assignment?

Do you need assistance with transportation? If so explain your needs.

What are your hobbies and interests?

Name two in-home activities you would most enjoy/appreciate.

Name two out of home activities you would most enjoy/appreciate.

What days would you prefer to have a volunteer?

What time of day would you prefer to have a volunteer?

Do you smoke?

Do you have a pet?

If yes what type?

Do you need physical assistance to get in or out of a car?

Are you willing to be assigned a volunteer of the opposite sex?

Use this space to tell us anything else we may need to know to match you with a volunteer.

Return completed application to:

Senior Companion Program Allies in Aging 1505 Avenue D. Billings, MT 59102

Angela Carter Program Manager (406) 259-3111