Brownsburg Older Adult Alliance, Inc. · Participant Enrollment

Date of Birth

*

(mm/dd/yyyy)

Gender

*

Male

Female

Prefer not to say

Name

*

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Email

Verify Email

Home Phone

Cell Phone

Preferred Way of Contact

*

Email

Home Phone

Cell Phone

Best Day/Time to Call

Is it okay to include your contact information on the activity contact list?

*

Yes

No

Are you a Veteran?

*

Yes

No

Do you have any allergies?

*

Yes

No

If yes, please mark all that apply:

Cat

Dog

Food

Smoke

Other

Activities Interest

Which areas are you interested in?

*

Companionship/Visits

Grocery Shopping/Errands

Transportation to Appointments

Social Activities

Seasonal Projects (leaf raking)

Household Repairs/Yardwork/Snow Removal

Emergency Contact (name & phone number)

Publicity release

I hereby authorize BOAA to record and photograph my image and/or voice in any promotional materials and/or media pieces relating to its program. I understand and agree that these audio, video, film and/or print images may be edited, distributed, reproduced, broadcast and/or reformatted in any form and manner without payment of fees in perpetuity. I understand that permission for media release is voluntary and in no way affects my ability to participate in BOAA.

I authorize publicity release as show above:

*

Yes

No