SC Senior Registration

Full Name*

First Name Last Name

Gender*

Male Female

Age

Phone Number

- Area Code Phone Number

E-mail

Address

Do you live in a Senior Facility/Assisted Living Care?

Yes No

Name of Senior Center

Room #

How often would you like a visit?*

Weekly Twice a month Other

What day of the week would be most convenient for a visit?*

What time of the day is best for you?*

: Hour Minutes

Would you prefer a volunteer that is?

Male Female No preference

Would you enjoy visits that include children?

Yes No

Do you have any hobbies or special interests you would like to be able to share with your visitor?

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Sunshine Club Senior Information Form