Community and Elder Application

Group Name: *

Primary Mailing Address for Group

Street: *

City: *

State: *

Zip Code: *

Primary Phone Number for Group: *

How did you hear about Bessie's Hope?: *

How often does your group intend to visit?: *

When are the best times for your visits?: *

Please give us an idea of when your group will be able to participate in our program.

Please have each volunteer complete this waiver and release: https://www.bessieshope.org/sites/default/files/Community%20and%20Elders...

Primary Group Leader

Contact information for the primary group leader.

First Name: *

Last Name: *

Street Address: *

City: *

Zip Code: *

Home Phone:

Cell Phone:

Email Address: *

Second Group Leader

Contact information for another adult assisting primary group leader.

First Name:

Last Name:

Street Address:

City:

Zip Code:

Home Phone:

Cell Phone:

Email Address:

Third Group Leader

Contact information for another adult assisting primary group leader.

First Name:

Last Name:

Street Address:

City:

Zip Code:

Home Phone:

Cell Phone:

Email Address:

Group Demographics

Please estimate the demographics of your group. This information is important for some of the grants that help Bessie's Hope exist.

Number of Adult Volunteers: *

Information about Youth Volunteers

Skip this if your group does not have youth involved.

Number of Youth Volunteers: *

Age Range of Youth: *

Number of Male: *

Number of Female: *

Number of Low Income: *

Number of African American: *

Number of Asian: *

Number of Caucasian: *

Number of Hispanic: *

Number if Native American: *

Number of "Other": *

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Community and Elder Application

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