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
Age:
*
Age
-
Month
-
Day
Year
Date
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HOBBIES AND INTERESTS
What are some hobbies or activities you enjoy? These can be long time passions or things you do occasionally. Examples could include playing any type of game (such as board games, mah jongg, chess, bridge, canasta, rummikub) cooking/sharing family recipes, sports/watching sports (particular types of sports), movies, theater, museums, concerts, making art, knitting, crocheting, needlepoint, crafting, playing an instrument, music, gardening, technology, speaking a foreign language, history, reading, travel.
SKILLS, TALENTS, EXPERIENCES YOU WOULD ENJOY TEACHING OR SHARING
Are there any things from your answer to the previous question that you’d like to share with someone else – or do you have other skills/interests that you’d like to share? For example, this could include such things as career mentoring, tutoring, interview coaching, teaching games, teaching cooking, teaching a musical instrument, teaching a foreign language.
MENTORING, SKILLS, OR ACTIVITIES YOU WOULD LIKE TO RECEIVE OR LEARN
Is there something you’ve always wanted to try or explore - from the examples above or any others! We can find a match to teach you!
TOPICS OR INTERESTS YOU ENJOY TALKING ABOUT
What subjects could you happily chat about for way too long? For example, do you enjoy talking about art, travel experiences, sports, books, history, family stories, careers?
WHAT ELSE WOULD YOU LIKE US TO KNOW ABOUT YOU
Is there anything else you would like us to know about you before we match you with another participant?
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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.)
Are there specific days and times that work best for you?
Days
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Hours Available:
OTHER INFORMATION
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Do you have any visual, hearing, or mobility impairment?
Do you have a visual, hearing, or mobility impairment?
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? (can be by zoom if participant is far).
Emergency Contact
First Name:
First Name
Last Name
Phone:
Format: (000) 000-0000.
E-mail Address:
example@example.com
Relationship:
Signature
I certify the information above is accurate.
Signature:
Date:
-
Month
-
Day
Year
Date
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