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Name *

First

Middle

Last

Date of Birth: *

Gender: *

• Male
• Female

Retired? *

• Yes
• No

Home Phone:

Cell Phone:

Email

Preferred Contact Method:

• Home Phone
• Cell Phone
• Email

Best Time to Contact You:

Address: *

City: *

State: *AlabamaAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip Code: *

Housing:

• Own My Home
• Rental

Living Status: *

• Alone
• with Caregiver
• with Spouse/Family/Friend

Pets:

• Dog
• Cat
• Other

If other, what?

Special Needs:

• Uses wheelchair
• Hearing Impaired/Aids
• Uses Mobility Device
• Low Vision
• Uses Service Animal
• Uses Companion Support
• Other

If other, what?

Emergency Contacts (Please list with name, phone number, address, & relationship):

If you should have a medical emergency while you are being transported by a Made to Stay volunteer, you will be taken to the nearest hospital emergency department. Your emergency contact person will be notified.

Primary Care Physician:

Office Phone Number:

Office Location:

Office City:

Specialist Physician:

Specialty:

Office Phone Number:

Office Location:

Office City:

Specialist Physician #2:

Specialty:

Office Phone Number:

Office Location:

Office City:

Dentist:

Office Phone Number:

Office Location:

Office City:

Optometrist:

Office Phone Number:

Office Location:

Office City:

Name of Pharmacy:

Pharmacy Phone Number:

Hospital of Choice:

How would you describe your health?

• Excellent
• Very Good
• Good
• Fair
• Poor

How many years have you lived in this community?

• 0-5 years
• 5-10 years
• 10+ years

What is your racial/ethnic background?

• African American
• Caucasian/White
• American Indian
• Hispanic/Latino
• Other

Do you speak a language other than English in your home? *

• Yes
• No

If Yes, please specify:

How interested are you in meeting new friends in your community?

• Very
• Somewhat
• Not Interested

How interested are you in participating in discussion groups (book clubs)?

• Very
• Somewhat
• Not Interested

How interested are you in attending monthly social events/luncheons?

• Very
• Somewhat
• Not Interested

How interested are you in participating in craft club activities?

• Very
• Somewhat
• Not Interested

How interested are you in participating in a card – game group?

• Very
• Somewhat
• Not Interested

How interested are you in participating in electronics training?

• Very
• Somewhat
• Not Interested

How important is transportation to medical appointments?

• Very
• Somewhat
• Not Important

How important is transportation for shopping & errands?

• Very
• Somewhat
• Not Important

How important is grocery delivery – volunteer shopping for you?

• Very
• Somewhat
• Not Important

How important is having weekly telephone checks about your well-being?

• Very
• Somewhat
• Not Important

When you think about living at home, are you concerned about personal safety?

• Very
• Somewhat
• Not Concerned

When you think about living at home, are you concerned about yard work?

• Very
• Somewhat
• Not Concerned

When you think about living at home, are you concerned about home repairs?

• Very
• Somewhat
• Not Concerned

When you think about living at home, are you concerned about help with medication?

• Very
• Somewhat
• Not Concerned

When you think about living at home, are you concerned about help with transportation?

• Very
• Somewhat
• Not Concerned

In the past 12 months how often have you stayed in the hospital?

Selected Value: 0

In the past 12 months how often have you visited the emergency room?

Selected Value: 0

In the past 12 months how often have you fallen in your home?

Selected Value: 0

In the past 12 months how often have you had problems hearing over the phone?

Selected Value: 0

In the past 12 months how many surgeries have you had?

Selected Value: 0

Are there any medical needs our staff/volunteers should be made aware of?

I give permission to use my name and photo in ads, brochures, the website and any other publications of Made to Stay. *

• Yes
• No

Submit

Made to Stay is a Kentucky not for profit corporation that is tax exempt under 501(c)(3) of the federal income tax law. Its goal is to help residents of McCracken county, age 55 and older, or adults with disabilities to stay at home in their community as they age. Made to Stay does this by connecting its members to the people and services necessary to maintain home, health, hope and happiness. It organizes community volunteers and service providers, who will often work at reduced prices. All personnel sent to members’ homes will have had substantial background checks.

Membership to Made to Stay costs $600 annually for a household of two or more, $360 for an individual. The membership year runs from July 1st to June 30 of the following year. When an individual is accepted for membership, there fee is prorated from that date to the end of that fiscal year. Membership fees are subject to change at the beginning of each new fiscal year. All members are subsidized in the sense that fees pay only a portion of the Made to Stay budget. Failure to pay dues will result in revocation of membership.

In exchange for a person’s acceptance by Made to Stay as a member, the member agrees to indemnify Made to Stay from and hold it harmless against any and all loss, expense and liability arising out of or related in any way to (1) the performance of Made to Stay and its agents and (2) the activities of any volunteer or service provider used or recommended by Made to Stay.

Privacy Policy
As part of this agreement, Made to Stay will not give, sell or trade a member’s information except in the event of an emergency situation involving the member whereby Made to Stay will contact the emergency contact(s) listed on the member’s General Information Form or local emergency resources.
Each of the undersigned applicants for Made to Stay membership states that he/she has read and understands the above terms of membership and agrees that he/she and their respective heirs, successors, agents, and legal representatives will be bound by those terms. When a membership is renewed, it will remain subject to this agreement.