Senior Companion Program 5-31-24

May 31, 2024

10:00 am – 11:00 am

Location: Lewis and Clark Library – 9909 Lewis and Clark Blvd, St. Louis, MO 63136

Presentation Description: Information about volunteering and receiving services from the Senior Companion Program.

Registration: Please REGISTER BELOW or call the Library at (314) 994-3300. Lunch donations are appreciated https://www.agingahead.org/donate/

"*" indicates required fields

Name*

First Last

Email*

Phone*

Are you a CHOICE member?*

Yes, I am a CHOICE member.

No, I need to sign up for the free CHOICE program.

Check Yes, if you have already filled out our 10 questions like address, birthday, primary race, etc. Check No, if you need to answer these additional questions.

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Birthdate (MM/DD/YYYY)*

Gender*

Ethnicity*

Primary Race*

Medicaid Eligible*

Rural*

Low Income*

Yes

Unknown

Use this chart to determine if you are low income - [1 in household: $1,040.83/month] [2 in household: $1,409.17/month] [3 in household: $1,777.50/month] [4 in household: $2,514.17/month]

Number in Household?*

Lunch Order

Lunch must be ordered 48 hours in advance, by Wednesday at 10:00am for the Friday class. We are unable to make changes to your meal order after registration. If you registered without ordering a lunch and would like to change that to a meal, please reregister with your meal order. We are unable to accommodate any changes made over the phone or by email. (Please note the program has a 5 lunch order minimum and lunches may not be available.)

Box Lunch Options (No Substitutions)*

Side Salad or Entrée Salad Dressing*

Milk*

Comments

This field is for validation purposes and should be left unchanged.

Senior Companion Program 5-31-24

Lunch Order

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