DURGA TEMPLE

(A Tax-Exempt Organization)

8400 Durga Place, Fairfax Station, VA 22039

Tel: (703) 690-9355 Web:http://www.durgatemple.org

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From: Senior Citizen Committee Members of Durga Temple. Date: ______

To participate in the activities specifically organized for our Seniors, pls. fill this form

______

Last Name M.I. First Spouse (First, M.I. & Last Name)

______

Address (Street, City, State, Zip)

Age Self: _____57 – 60; _____ 61 – 64; _____ 65 – 69; _____ 70 – 74; _____ 75 – 80; _____80Yr

Spouse: _____ 57 – 60; _____ 61 – 64; _____ 65 – 69; _____ 70 – 74; _____ 75 – 80; _____>80Yr

Home Tel. No. (_____) ______-______. Other (cell/work) Tel. No.: (_____) ______-______

E-Mail:______. Other E-Mail______

Do you live with someone? ___Yes ___No. If Yes, please specify______

Do you own car or access to one?___Yes ___No. If so, can you give ride? ____Yes, ____No

Can you get a ride to temple?___Always, ___Most of the time, ___Sometimes, ___Not Available

Do you have Medical Insurance?___Yes, ___ No. Are you a US Citizen/Immigrant?___Yes ___No

Your primary Physician______Tel. No. (_____) _____-______.

Comfortable with: ____English, ____Hindi, ____Punjabi, ____Gujrati, ____Any other?______

Do you have skills which you would like to share with others? ____Yes, ____No. If yes, pls. tell us:

____Music, ____Craft, ____Yoga, ____Religion, ____ Others, pls. specify______

Are you a member of Durga Temple? ____ Yes, ____ No. If not, please become a member of the temple TODAY. Your generous financial contribution and time will always be appreciated.

Please provide any other information ______

Our committee has made a list of activities that we will need to prioritize after we hear from you.

PLEASE NOTE: Our primary purpose to undertake this effort is to serve YOU. Therefore, we only want to facilitate what you collectively (as a group) would like us to organize for you. Please contact any of the senior citizen committee or Exec. Board members. We look forward to hear from you all.

Pls. mail completed form to: Durga Temple (Address Above) Attn: Senior Citizen Committee