New Membership - Made To Stay

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MEMBERSHIP

GET THE HELP YOU NEED TO STAY IN YOUR HOME

New Membershipadmin2023-09-16T21:01:42-05:00

how we help

Membership includes up to 8 service requests per month

Services include:

Transportation
Escorted Transportation
Small home repairs
Yard work – small jobs
Technical assistance – computers, tv, phones, etc.
Home office – financial organization
Home organization
Social events
Wellness and fitness

Services do not include:

sitter-service
support typically provided by nurses or nursing assistants
personal care (bathing, feeding, or dressing)
administering medications

Membership cost

Our membership fees run $360 per year for one individual, or $600 for a household.

Payments can be made monthly, quarterly, or annually. Scholarships may be available for those who qualify for reduced fees. Contact our direction Sarah for more information.

Services Provided in 2023

membership application

Please enable JavaScript in your browser to complete this form.

Name *

First

Middle

Last

Date of Birth: *

Gender: *

Male
Female

Retired? *

Home Phone:

Cell Phone:

Preferred Contact Method:

Home Phone
Cell Phone
Email

Best Time to Contact You:

Address: *

City: *

State: *

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? *

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. *

MEMBERSHIP

GET THE HELP YOU NEED TO STAY IN YOUR HOME

how we help

Membership includes up to 8 service requests per month

Membership cost

membership application