Private Senior Information Submission

Please submit this form for a senior with private/family care who wishes to have a visit.

If you do not receive an email confirmation of this submission within 5 minutes of when you submit it, please call us at (862) 243-5331.


Please let us know any details that you think would be helpful for the volunteers to know. For instance, what was the senior's job/profession, where did they grow up, what are/were their favorite hobbies? Our volunteers will be able to use some of this information to begin a conversation, and then develop a rapport with the senior.
Also, let us know if there are any unique details about this particular senior's cognitive issue that we should make our volunteers aware of. For instance, does the resident think that they are on a cruise, in a hotel, etc.; do they have a lack of short-term memory; are there any "trigger words" or topics that our volunteers should make sure to avoid that are specific to this senior?


What day(s) and time(s) is this senior available for the 1 hour call (our volunteers are available weekdays and / or weekends)? The more options you provide, the easier it will be to find students who are available.

Monday:

Tuesday:

Wednesday:

Thursday:

Friday:

Saturday:

Sunday: