Private Caregiver Senior Information Submission Please submit this form for a senior with private/family care who wishes to have a visit. Private Care Senior Interest Form Contact Person Name Contact Person Phone Alternate Contact Person Alternate Contact Person Phone City State - Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingConfirmation Email If you do not receive an email confirmation of this submission within 2 minutes of when you submit it, please call us at (862) 243-5331. Senior InformationSenior's Name Please let us know any details that you think would be helpful for the volunteers to know. For instance, what was the senior's job/profession, where did they grow up, what are/were their favorite hobbies? Our volunteers will be able to use some of this information to begin a conversation, and then develop a rapport with the senior. Also, let us know if there are any unique details about this particular senior's cognitive ability that we should make our volunteers aware of. For instance, does the senior think that they are on a cruise, in a hotel, etc.; do they have a lack of short-term memory; are there any "trigger words" or topics that our volunteers should make sure to avoid that are specific to this senior?Senior Information What day(s) and time(s) is this resident available for the 1 hour call (our volunteers are available weekdays and / or weekends)? The more options you provide, the easier it will be to find students who are available.Monday Tuesday Wednesday Thursday Friday Saturday Sunday Time Zone -Select-Atlantic Standard TimeEastern Standard TimeCentral Standard TimeMountain Standard TimePacific Standard TimeAlaskan Standard TimeHawaii-Aleutian TimeSubmit