Senior Outreach Survey

COA Senior Outreach Survey:    Please    check or circle   responses that apply to you and fill in appropriate information where requested:

Name:

I am:        a.)  60 or older                    b.)  younger than 60  

Your preferred contact method: (all that apply)       

Phone        Texting       email      Regular mail

List addresses for above:

 

 


I am interested in participating in an exercise program in the following way(s):

Exercising at home alone to a video

Exercising with a small group in a home setting to a video

Exercising with a small group in a home setting with a live teacher/leader

Exercising in a community room setting to a video

Exercising in a community room setting with a live teacher/leader

 Other:

 

I am willing to:

host a small exercise group in my home.

lead a small exercise group in a home setting.

organize a small exercise group in a community room setting.

lead a small exercise group in a community room setting.

provide/organize transportation for Senior Citizens to participate in an exercise group.

 

List other activities you wish to participate in that are not currently available in your area.

 

 

 

 

COA: 4/27/2016