|
|
4101 East Genesee Street*Syracuse, New York 13214*Telephone (315) 446-9111
Name___________________________________________________________Date_____________
Address_________________________________________________________________________
City, State, Zip________________________________________________________________
Home Phone______________________________________________________________________
D.O.B.__________________________________________________________________________
Occupation______________________________________________________________________
Volunteer Experience(s)_________________________________________________________
Referred by_____________________________________________________________________
Program Interest Program Assigned
Adult Day_______________________________________________________________________
Friendly visitor________________________________________________________________
Special events & activities_____________________________________________________
Transporting residents__________________________________________________________
Outings_________________________________________________________________________
Arts & Crafts___________________________________________________________________
Gift Shop_______________________________________________________________________
Receptionist____________________________________________________________________
Jewish Programming______________________________________________________________
Religious services______________________________________________________________
Current events__________________________________________________________________
Teaching a class: Painting___________________
Ceramics___________________
Knitting___________________
Other___________________