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