Getting to know you.

Abstract

Name: __________________________________________ Room #: _________ Record #: ________ (If applies) Last First Middle Phone #: ________________________ (If installed) What do you prefer to be called? ______________________________ Sex: M F Birth Date: ____________ Move-in date: _________ Where did you move here from? _____________ How long did you live there? ________ Is there someone you would like us to contact or send information to regarding activity programs? Yes No Contact Person: Name: __________________________ Relationship: ____________ Phone #: (H) ______________ Address: _________________________________________________ (W)______________ E-mail: __________________________________________________ Marital status: M D W S If married, spouse’s name: _________________ and Anniversary Date: _______ How many children do you have? ___________ Do you have any grandchildren / great grandchildren? _____ /_____ Do you have family/friends in the area? _____________________________________________________ Do you know someone who lives here? Who? ________________________________________________ Where were you born? _________________________________ Language(s) spoken: ________________________ Where have you lived/traveled? ________________________________________________________________ Where did you go to school/college? __________________ Former/present occupation(s): ______________________ Were you ever in the military? Yes No Branch of Service: ______________________ Dates: _____________ Would you like to share your religious affiliation? _____________________ Attend regularly? Yes No If yes, would you like us to contact? Yes No Contact person and phone # _________________________________________ Can we help you with voting? Yes No If yes, prefer to vote: Absentee Go to the polls Do you need assistance with change of address or registering to vote? Yes No Belong to any clubs/organizations? (past or present) Officer? ______________________________________ Involved in volunteer work? (past or present) _________________________________________________ Do you enjoy pets? Have a pet? What kind? Name? ____________________________________________ Do you still drive? Have a car? __________________________________________________________ What kinds of things do you enjoy doing? Any hobbies, talents, or special interests? Are there things you did in the past you might like to try again? Is there something you have always wanted to do or might like to try? (Ask in particular about specific programs you have going on in your community.)