Senior Companionship Service Application Form
Please fill out the following information to apply for membership.
Full Name
First Name
Last Name
Date of Birth
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
First Name
Last Name
Emergency Contact Phone Number
example@example.com
Emergency Contact Relationship to the senior
example@example.com
Communication Preferences
Phone
Handwritten Letters
Text
Video Calls
Email
Other
Interests
Talking and sharing stories
Crafts or creative activities
Reading Together
Music or Movies
Puzzles or word games
Walking or sitting outside
Looking through Photos
Letter Writing
Light Conversation
Pets and animals
How would you describe your personality?(Such as: quiet, talkative, warm, thoughtful, structured, flexible, humorous, etc.)
Do you prefer a companion who is more:
More talkative
A good listener
Calm and gentle
Energetic and outgoing
What is your comfort level with new people?
Very comfortable
Somewhat comfortable
Hesitant / takes time to warm up
Comfort and Boundaries. Are there any topics you prefer not to discuss? Are there any personal boundaries we should know?
What do you hope to gain from having a companion?
Submit
Should be Empty: