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Steps

1. Personal and Contact Information This section is complete This section is incomplete
2. Housing Information This section is complete This section is incomplete
3. Emergency Information This section is complete This section is incomplete
4. Mailing List Survey This section is complete This section is incomplete

Personal and Contact Information

First Name*
Middle Initial
Last Name*
Nickname (Alias)
How would most people know you?
Gender*
Birthdate*
Birthdate
Physical Address*
Mailing Address (If different from Physical)
City*
State*
Zip Code*
Primary Phone Number*
Secondary Phone Number
Primary Phone Number is:
1. Home Phone
2. Cell Phone
3. Work Phone
Secondary Phone Number is:
1. Home Phone
2. Cell Phone
3. Work Phone
My preferred communication method is:
Select all that apply
1. Phone Call
2. Text Message
3. Email
Please do not contact me using:
Select all that apply (note this will only apply to robocalls/group messages by the Agawam Council on Aging)
1. Phone Call
2. Text Message
3. Email
4. Any of the Above
Ethnicity*
Ethnicity (Other):
Email Address
Continue

Housing Information

Are you the head of house?*
Do you live alone?*
Do you live in a rural area?*
Residence Type*
Continue |Go Back

Emergency Information

Emergency Contact First Name*
Emergency Contact Last Name*
E-Contact Primary Phone*
E-Contact Secondary Phone
E-Contact Relation to You*
Primary Phone is:*
1. Home Phone
2. Cell Phone
3. Work Phone
Secondary Phone is:
1. Home Phone
2. Cell Phone
3. Work Phone
Second Emergency Contact
Emergency Contact First Name
Emergency Contact Last Name
E-Contact Primary Phone
E-Contact Secondary Number
E-Contact Relation to You
Primary Phone is:
1. Home Phone
2. Cell Phone
3. Work Phone
Secondary Phone is:
1. Home Phone
2. Cell Phone
3. Work Phone
Do you have any disabilities?*
Please note: If you answer "Yes" to this question, a staff person will follow up with you for more information.
1. Yes
2. No
Do you have any allergies?
Please note: If you answer "Yes" to this question, a staff person will follow up with you for more information.
1. Yes
2. No
Continue |Go Back

Mailing List Survey

Would you be interested in receiving a monthly newsletter by mail if it were at no cost to you?
1. Yes
2. No
Would you be interested in a newsletter mailing if it were for the cost of postage (approximately $6 per year)?
1. Yes
2. No
Do you currently subscribe to our newsletter via email?
1. Yes
2. No
3. Please send me the link to subscribe

Leave This Blank:

1. Receive an email copy of this form.
Email address

This field is not part of the form submission.
Submit Submit and Print | Go Back

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The Town of Agawam
36 Main Street
Agawam, MA 01001
Phone: 413-786-0400
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