Adopt-a-Senior Report Form

2. Adopt-a-Senior Report

4. Volunteer First Name*

5. Volunteer Last Name*

6. Date of Service*
   Date of Service

8. Address of Your Adopted Senior*

9. City*

10. State*

12. Clean-up Metrics

14. Hours of service*

15. Square footage of space painted*

17. Estimated weight (in pounds) of all litter removed (food wrappers, plastic bags, etc.)*

18. Estimated weight (in pounds) of all yard waste removed (grass, weeds, etc.)*

20. (Optional) Share some photos with us!

22. (Optional) Upload a before image from your service

23. (Optional) Upload a during or after image from your service

25. (Optional) Upload an image with your adopted seniors

Leave This Blank:


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

    This field is not part of the form submission.

29. Submit Submit and Print

* indicates a required field