Person completing this form
Please provide your contact information so that we can reach you if we have any questions about this form. This information will not be shared or made public for any reason. You will also be the primary contact person for future internal Age Friendly Network communications. You can indicate your organization's public contact information for clients below.
Your Name *
Your Name
Your Phone Number *
Your Phone Number
Organization Description
Please complete this section to the best of your abilities. This will help us to organize and categorize all of the different network services and resources.
Please state your organization's mission and vision statement(s) if applicable. Please write N/A if this does not apply to your organization.
Organization Type *
Please select ALL that describe your organization.
Briefly describe the services or products your organization provides to the community. Please use friendly language that can be easily understood by everyone. This brief description may be used on the Age Friendly website or in other future Age Friendly resources. What is the elevator pitch? What do you want the community to know about your organization's services?
Do residents need to meet specific criteria in order to use your services? (i.e. income-based, geographic, insurance, etc.) This question will help residents to know what to expect when they contact your organization.
Domains of Livability *
Please select the domain area(s) that best describe your organization's services. For example, if a resident is looking for information about your services, under which domain(s) would you most likely be found?
Organization Contact Information
This information will be posted on the Age Friendly Erie County website and will be shared in other Age Friendly Erie County resources. We are committed to connecting PEOPLE to PEOPLE for effective information sharing. We require a HUMAN contact for residents to reach your organization. Please do not list a number or email where residents will be connected to a robot or automated operator. Thanks.
Contact Person
Contact Person
Phone *
More Information
Age Friendly Erie County will begin communicating with network organizations more regularly. The person completing this form will be the primary contact for Age Friendly Network communications.
Our organization would be interested in the following:
You may select as many as you wish. You will always have the opportunity to "opt out" of Age Friendly Network Communication in the future.