Senior Companionship Service Application Form

Senior Companionship Service Application Form

Please fill out the following information to apply for membership.
Full Name

First NameLast 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

CityState / Province

Postal / Zip Code
Emergency Contact

First NameLast Name
Emergency Contact Phone Number
example@example.com
Emergency Contact Relationship to the senior
example@example.com
PhoneHandwritten LettersTextVideo CallsEmailOther
Talking and sharing storiesCrafts or creative activitiesReading TogetherMusic or MoviesPuzzles or word gamesWalking or sitting outsideLooking through PhotosLetter WritingLight ConversationPets and animals
How would you describe your personality?(Such as: quiet, talkative, warm, thoughtful, structured, flexible, humorous, etc.)
More talkativeA good listenerCalm and gentleEnergetic and outgoing
Very comfortableSomewhat comfortableHesitant / 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?
Should be Empty: