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Konocti Senior Support

Friendly Visitor application

Name*

Phone number*

Email Address*

Date of Application*

Are you at least 20 years of age?*

YesNo

Why are you interested in becoming a Friendly Visitor? Please describe.*

Have you had experience with aging parents, grandparents, etc? Please describe.*

What qualities do you have that you feel would help you relate well with seniors?*

Do you have any health or transportation problems that need to be addressed in order for you to participate in this program? Please describe.*

List some of your previous employment/volunteer activities that relate to seniors or homebound persons.*

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Konocti Senior Support, Inc. [email protected]