Americorps Seniors
Senior Companion Program
Please use this survey for both client and outpatient procedure referrals.
Questions? Please call Courtney (317)-236-1555
Information is required to meet federal grant guidelines
1.
Today's Date
2.
First and last name
3.
Date of birth
4.
Home Address
5.
Phone number
6.
Do you prefer to receive information by
Call
Text
7.
What program would you like to receive more information about?
Becoming a Senior Companion
Outpatient Procedure Transportation
Having a Senior Companion visit me