Senior Sign-up Form for Women

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 treats:

Any dietary restrictions:

Favorite type of tea/coffee:

Favorite kinds of music:

Favorite types of books/magazines:

Favorite animal, or animals:

Favorite color, or colors:

Favorite flower, or flowers:

T-Shirt size:

Do you enjoy: candles incense potpourri sachets bubble bath shower gel body sprays scented soaps body lotion bath salts angels

What is your preference in fragrance: fruity scents floral scents fresh scents

Do you enjoy: crossword puzzles stationery/note cards

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 spiritual belief:

...no thank you, no religious material please

Briefly describe senior's current health conditions:

Name of spouse, if married:

If there is anything else you can think of... things senior collect, things that cheer her up, things she likes to do, etc...please indicate in the following text box. 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:

Senior Application for Women

Contact Person