PARTICIPANT APPLICATION FORM
PERSONAL INFORMATION
Full Name:
First Name
Last Name
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone:
Format: (000) 000-0000.
Email:
example@example.com
Date of Birth:
-
Month
-
Day
Year
Date
Emergency Contact
First Name:
First Name
Last Name
E-mail Address:
example@example.com
Phone:
Format: (000) 000-0000.
Relationship:
Back
Next
Save
INTERESTS
What are your interests and hobbies? What do you enjoy doing for fun? Please be as specific as possible and include any activities or subjects about which you are particularly passionate or which you would enjoy sharing with/teaching to others. Examples could include, but certainly are not limited to, learning languages, art, music, sports, gardening, walking, reading, history, crafting, or games (including specific types of games, such as mah jongg, bridge, or board games).
Do you have a certain expertise/skill that you would like to share with another participant? This could include mentoring about a career, tutoring, helping others learn another language, including helping foreign language speakers learn English. Please feel free to include as many as you would like.
Is there a skill, hobby, profession, or something else you are interested in learning or getting help with?
What did you do as a career (if applicable)?
Is there anything else you would like us to know about you before we match you with another participant?
Back
Next
Save
What age group would you prefer to connect with? (check as many as you wish)
**NOTE: At least 1 participant of each match must be in the over 62+ age group
Age Group Preference
Preschool - 1st Grade
7 – 12 years
13 years – 18 years
Adults 18 – 62
62 +
Other
AVAILABILITY
How frequently would you be interested in meeting another participant with whom you are matched? (e.g., 1x/week, 1x/month, 2x/month.)
What Days and Times work best for you?
Days
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Hours Available:
OTHER INFORMATION
Back
Next
Save
Hearing:
Hearing:
Good
Fair
Poor
Vision:
Vision:
Good
Fair
Poor
Mobility:
Mobility:
Good
Fair
Poor
Have you, since attaining the age of 18, been convicted of a criminal offense?
No
Yes
Background Checks
Do you consent to a required background check?
Yes
No
WHAT DAYS/TIMES WORK BEST FOR US TO SCHEDULE AN IN- PERSON INTERVIEW WITH YOU?
Signature
I certify the information above is accurate.
Signature:
Date:
-
Month
-
Day
Year
Date
Save
Continue
Continue
Should be Empty: