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Registered Angels, click here to go to Angel's Corner...

You can make a difference!

Your support is urgently needed. Help us continue to bring a ray of sunshine to those battling cancer...

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Chemo Angels
P.O. Box 1971
Julian, CA 92036

USA

E-mail us...
 

 

 

 

Senior Application for Men

 
Name:
Address:
City, State, Zip:
Country:
   
Telephone No:
E-mail address:
   
Birthday:
Age:
   
Briefly tell us about senior and describe any Hobbies/Activities:
   
Favorite (mailable) snacks and/or treats:
   
Any dietary restrictions:
   
Favorite type of tea/coffee:
   
Favorite types of music:
   
Favorite types of books/magazines:
   
Favorite animal or animals:
   
Favorite sport & sports team:
   
T-Shirt size:

Do you like scented soaps, after shaves, etc?   yes!  

If yes, what type of scents to you like?:   musk   citrus   woodsy   spicy   other...specify 

Do you enjoy crossword puzzles?   yes!

Do you prefer...   VHS (video tapes) or DVD's   VHS   DVD's     

Cassette tapes or CD's   cassettes   CD's

Do you celebrate:   Christmas   Hanukah   other...specify  

If religion is important in senior's life, please tell us which religion or type of spirituality:

                    nothing  religious please  

Briefly describe senior's current health condition:
   
Name of spouse, if married:

If there is anything else you can think of... things senior collects, things that cheer senior up, things he likes to do, etc...please indicate so in the following text box. It has been our experience that men are more challenging to "angel" than women. Any further information you can give us would be greatly appreciated. Thank you!

 

Contact Person

Every senior must have at least one, preferably two contact people -- a close friend, relative or facility staff person who generally knows what is going on in the seniors life. This person must have an email address which must be different than senior's, if senior has one.

Contact Persons Name:
   
Contact Persons e-mail address:  
   
Contact Persons mailing address:
   
Relationship to applicant:
   
  Alternate Contact Person
#2 Contact Persons Name:
   
#2 Contact Persons e-mail address:
   
#2 Contact Persons mailing address:
   
#2 Contact Relationship to applicant:
   

There are times when some extra attention and encouragement may be helpful. During such a time we have "Special Assignment Angels" who send cards, letters of support, and perhaps a small gift to those in need of some extra cheer. If you do not wish to have your address given to the Special Assignment Angels at any time, please indicate so below. Regardless of which option you choose, senior's address and information will never be given to anyone outside of our organization.

yes, if needed, senior would love to be the recipient of a Special Assignment

no Special Assignment please. Only give out address to assigned Angel.

 

If you are submitting this application for someone else, please give the following information about yourself. Thank you!

Your name:
   
Your e-mail address:
   
Your relationship to applicant:
   
   
How did you hear about Senior Angels:  
   

 

 

 

 

  

 
   

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