Dakota GWEP Tellegacy:  Older Adults Sign-Up Form
University Student meets weekly via phone/virtual meeting for friendly conversation, and listening to older adults sharing their stories, their goals, and their legacy.
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First and Last Name *
Name of Community and/or City/State
Phone Number *
Email *
How did you hear about the program?
(if applicable) Email or Contact of whom referred you to the Program.
Older Adult Gender
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Older Adult's Marital Status
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Do you have any children?
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Where did you grow up (City, State, etc.)?
What do you do for a living (job, career, volunteer, retired...)?  
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Please list some things that are important to you (religion, family, reading, music, etc.).
What do you like to do independently (watch tv, word searches, read, listen to music, etc.)?
Please list some things you like in general (foods, pets, type of music, etc...).
Who would you like to meet with?
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Best Day/Time to Contact *
Consent to Participate in Tellegacy Program
• By selecting the "I Accept" button, you (older adult) are agreeing to participate in a trial of the Tellegacy Program. You will be matched with a college student (Legacy Builder) who will contact you at designated times via telephone or virtual visit, as agreed upon ahead of time. The intent of the calls/virtual visits are to make intergenerational connections and to allow the older adult to share stories with the Legacy Builder. The Legacy Builders are not trained counselors or professionals and the sessions do not constitute as mental health counseling. The goal of the program is to help combat loneliness and social isolation and instill a sense of hope and purpose. The recipient has the right to Opt Out of the Tellegacy Program at any time by notifying the contact at their facility, Legacy Builder, or Tellegacy team. Each older adult will be treated with dignity, respect and kindness during the Program and will report any concerns to the program lead immediately. Older adult agrees to treat the Legacy Builder with dignity, kindness and respect as well. The older adult agrees to share their weekly or monthly goals, and their past life experiences with the Legacy Builder. The Legacy Builder agrees to respect and honor the life experiences of the older adult. Older adult agrees that a Legacy Book will be created and given to the older adult as a summary of the discussions at the end of the program.
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Anything Else You Would Like Us To Know About You (Contact: Dr. Jeremy Holloway at jeremy.holloway@tellegacy.com, or 419-270-7511 for any additional questions.)
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