Resident Information Submission Please submit this form for each resident who wishes to have a visit. Community resident information form Senior Community InformationCommunity NameCityState- Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingCommunity Contact PersonContact Person PhoneCommunity Alternate Contact NameAlternate Contact PhoneConfirmation EmailIf you do not receive an email confirmation of this submission within 2 minutes of when you submit it, please call us at (862) 243-5331. Resident InformationResident NamePlease let us know any details that you think would be helpful for the volunteers to know. For instance, what was the resident'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 resident. Also, let us know if there are any unique details about this particular resident'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 resident? Resident informationWhat day(s) and time(s) is this resident 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.MondayTuesdayWednesdayThursdayFridaySaturdaySundayTime Zone-Select-Atlantic Standard TimeEastern Standard TimeCentral Standard TimeMountain Standard TimePacific Standard TimeAlaskan Standard TimeHawaii-Aleutian TimeSubmit
