Icon Senior Community Hub – Pre-Registration
⚠️ Spots are limited. Completing this form does NOT guarantee placement — we will contact you to confirm availability.
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Participants Name
First Name
Last Name
Participants Gender
Male
Female
Prefer not to say
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Caregivers Name (if applicable)
First Name
Last Name
Caregivers Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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What activities interest you?
Music
Games
Exercise
Socialization
Crafts
Plants
Outings
What days are you interested in coming?
Monday
Tuesday
Wednesday
Thursday
Friday
Preferred Schedule
Full day
Half Day
Type option 3
Type option 4
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Does the participant require assistance with:
Eating
Speaking
Medication Reminders
Walking/ Mobility
Other
Mobility Status
Independent
Walker
Cane
Wheelchair
Any Diagnosed condition we should be aware of?
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When are you looking to start?
Immediately
Within 2 weeks
Just Exploring options
Do you need transportation?
To the Center
From the Center
Both
No transportation needed
Unsure
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How will services be paid?
Private Pay
Medicaid
Medicare Advantage
Veteran Insured
Not Sure
Need Assistance
If Medicaid or VA: Do you have a case manager?
Yes
No
Not sure
If yes Name of case manager
First Name
Last Name
If yes Number of case manager
Please enter a valid phone number.
Format: (000) 000-0000.
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Would you like a call to secure your spot?
Yes (call me ASAP)
Text me instead
Not yet
Submit
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