RSVP “A Walk Down Memory Lane”A Prom for ALL Senior Citizens!Prom RSVP 2 Please enter the information for the senior citizen attending the Prom in the first section below. Please enter the information for the senior's “plus one” (this can be a friend, family member, or professional Caregiver) in the second section below. Please note that a "plus one" is not required to attend the Prom with the senior citizen.If you need help filling out this RSVP form or have any questions about the Prom, contact Gretchen at 347-678-9912 (via text or call), or email gretchen@avilahomecare.com. Thank you!Information for the Senior Citizen Attending the PromName * Name First First Last Last Address * Email * If the senior does not have an email address, please write the email address of another person who can contact the senior on Avila’s behalf. Primary Phone * If the senior does not have a home phone or cell phone, please write the phone number of another person who can contact the senior on Avila’s behalf. Is the Primary Phone Number a Cell Phone or a Home Phone? * CellHome Male or Female * MaleFemale This is so we know how many boutonnieres vs. corsages to have for the Prom guests. Date of Birth (please enter in XX/XX/XXXX format) * Does the Senior Live... * In their own homeAt a friend or relative’s homeAt a Senior Living CommunityOther Which Senior Living Community? BlakehurstBrightview Mays ChappelBrightview Perry HallBrightview TowsonBrightview White MarshBrightwoodBroadmeadCharlestownCollege ManorCharter Senior Living, Cottages of Perry HallCharter Senior Living, TowsonCharter Senior Living, Woodholme CrossingEdenwaldInspirations LuthervilleJoyous LivingKeswickLevindaleLorien Mays ChapelMasonic HomesMercy RidgeNorth OakOak CrestPark View at TowsonPickersgillRoland Park PlaceSeaton TowsonSpringhouse Assisted LivingSpringwellStella MarisSymphony ManorSunrise PikesvilleTrinityOther If Other, Where Does the Senior Live? Does either the Senior or the plus one Have a Wheelchair or Have Any Other Accessibility Needs? * YesNo What is the Senior's Favorite Song?We’d like to know their favorite song so that the DJ can add it to his playlist for the Prom. Title of Song Name of the Musician Section Buttons Information for the Senior's “plus one” (this can be a friend, family member, or professional Caregiver)Name Name First First Last Last Please Indicate Whether the "plus one" Is a Friend, Family Member, or Professional Caregiver, or Other. FriendFamily MemberProfessional CaregiverOther If Other, please let us know the relationship to the Senior. Address Email Primary Phone Is the Primary Phone Number a Cell Phone or a Home Phone? CellHome Male or Female MaleFemale This is so we know how many boutonnieres vs. corsages to have for the Prom guests. Section Buttons Emergency ContactIf the Emergency Contact is someone other than the "plus one" who is attending the Prom with the Senior, or if the Senior does not have a "plus one" attending the Prom with them, please fill out this section.Name Name First First Last Last Address Email Primary Phone Is the Primary Phone Number a Cell Phone or a Home Phone? CellHome Relationship to Senior Section Buttons Additional InformationHow Did You Hear About the Prom? (Please click all that apply) * Invitation post card received in the mail Invitation post card received another way Flyer Email Message Avila Home Care’s Website Social Media News Media Other If Other, Please Specify From Whom Did You Hear About the Prom? (Please click all that apply) * Avila Home Care Alzheimer’s Association Loyola Blakefield LifeBridge Health Senior Placement Navigators Inspirations Memory Care GBMC Gilchrist Baltimore Consulting Kelly Benefits Brightview Senior Living Towson The Option Group Other If Other, You may write an organization or individual person’s name here * I authorize Avila Home Care and Prom co-sponsors to use my (and a “plus one” guest’s if there is one) photo and/or video image for websites, and/or social, print, and/or television media and/or other publications. Section Buttons If you are human, leave this field blank. Submit
