JP@HOME MEMBER INTAKE

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Dear Members,


The information we gather in the intake form below will help us better serve our members’ needs; develop programs and activities that are timely, relevant, and engaging; and provide a potential foundation or government funder with demographic information they are now requiring to be considered for grants.

 

Age, race/ethnicity, income level, homeownership, disability, veteran status, and other personal information, which we routinely collect for other Ethos programs, is kept strictly confidential and is only shared with potential funders in aggregate. We ask that you be as thorough as possible, and complete all of the required fields. 


Thank You!


Member Services

CONTACT INFORMATION









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DEMOGRAPHIC INFORMATION

















Please leave unchecked if NO and continue to next question.
Please leave unchecked if NO and continue to next question.

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INTERESTS


Please tell us how important the following are to you as you age:


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HEALTH/EMERGENCY/MEDICAL INFORMATION (OPTIONAL)








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