Personal Information Name Age Sex Date of Birth Street Address City Zip Home Phone Cell Phone Email Drivers License # Social Security # Volunteer Preference Volunteer Options Choose One One visit/week Two visit/month Other What day of the week do prefer to visit your senior buddy? Preferred Location Choose One Assisted Living Facility Private Residence Are there any family members who might accompany you on our visits? If yes, please fill in their info Name Age (if a child) Relation Any special talent that you might be able to share with your senior buddy? What do you hope to accomplish by being a part of Smile on Seniors Personal Reference Please list two reference who are not related. Name Relationship Phone Name Relationship Phone Emergency Contact Name Phone This page uses 128 bit SSL encryption to keep your data secure.
