Building a community for all ages

TimeBank Application Form for Individuals

Member Information

First Name*:

Last Name*:

Age*:

Street Address, City, State, Zip*:

Best Contact Number*:

Email Address*:

2. Gender

FemaleMaleGenderqueer/Non-binaryPrefer not to say

Service Checklist (Check off all that apply)

Services	I can Offer	I would like to Receive
Technology
“How to operate a tablet/ a cell phone/ Zoom” webinar	I can OfferI would like to Receive
	I can OfferI would like to Receive
Health and Wellness
Virtual stretching/ Tai Chi/ yoga/ meditation classes	I can OfferI would like to Receive
	I can OfferI would like to Receive
Hobbies
Virtual knitting/ crafting/ painting classes	I can OfferI would like to Receive
Virtual baking/cooking classes	I can OfferI would like to Receive
Participate in virtual live music event hosted by Senior Center	I can OfferI would like to Receive
Virtual game/ book club (facilitator sharing their screen)	I can OfferI would like to Receive
	I can OfferI would like to Receive
Housing Assistance
Provide suggestions on basic home repair solutions	I can OfferI would like to Receive
Help with connecting to a trustworthy handyman via telephone, text, or online	I can OfferI would like to Receive
Provide support on yard work, gardening, or basic snow removal	I can OfferI would like to Receive
	I can OfferI would like to Receive
Community Assistance
Admin support for Age-Friendly Glen Cove (e.g.: attending virtual community meetings, creating surveys and lists)	I can OfferI would like to Receive
Admin support for timebanking	I can OfferI would like to Receive
Admin support for other organizations	I can OfferI would like to Receive
	I can OfferI would like to Receive
Teaching
Tutoring/mentoring (e.g.: teaching language, finance, art…):	I can OfferI would like to Receive
Test prep: (circle subjects) GRECitizenGED	I can OfferI would like to Receive
	I can OfferI would like to Receive

Personal References (Personal references must be 21 years of age or above.)

First Name*

Last Name*

Middle Initial

Relationship

Email Address

Phone Number*

First Name*

Last Name*

Middle Initial

Relationship

Email Address

Phone Number*

Building a community for all ages

TimeBank Application Form for Individuals

Member Information

1. Do you speak English?

Do you speak another language?

2. Gender

3. Ethnicity

4. Employment Status

5. How comfortable are you using any online meeting software (e.g.: Zoom, Microsoft Teams, Google Meet, etc.) to participate in a virtual meeting?

6. What is your preferred meeting software?

Service Checklist (Check off all that apply)

Personal References (Personal references must be 21 years of age or above.)