Forms • Collinsville, OK • CivicEngage

Collinsville Senior Survey

If you would like to be notified or contacted about upcoming Senior Activities please fill out the contact information below. You can complete the survey without sharing your contact information as well.

Name:

Address:

City:

Zip:

Phone:

Email:

Would you like to be contacted about upcoming activities?

YES

NO

What is your age:

	60-64
	65-69
	70-74
	75-79

	80-85
	85-89
	90+

Senior activities you would like to have available here in Collinsville (Please check all that are of interest):

ORGANIZED ACTIVITIES

	Bingo
	Card Games
	Dominoes
	A place to sit and talk with other seniors.

	Sing-alongs
	Concerts
	Guest Speakers
	Bunco

CREATIVE ARTS:

	Painting
	Sculpting
	Drawing

	Woodworking
	Coloring
	Scrapbooking

HELP OR ADVICE ON:

	Home Repairs or Maintenance
	Cooking

	Computers/Internet
	Gardening

LIFE STYLE/MULTISENSORY ACTIVITES

	Yoga
	Tai Chi
	Pet Therapy

	Gentle physical exercise like walking
	Chair Aerobics

OTHER ACTIVITIES

	Occasional organized group trips
	A way to share wisdom with young people
	Book Club
	A place to sit and talk with other seniors.

	Remote Control Trains
	Leather work
	Geneology

Other activities not mentioned that you would be interested in:

When would you most likely be able to participate?

Mornings

Afternoons

Do you have transportation:

YES

NO

Any other comments/suggestions/ideas?

Thank you for your input!
We appreciate you taking the time to complete the survey. We hope to have an activity program for seniors in our community very soon.

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