Patron Application Form
This form is to request a visitor. Please contact if you have any questions.
Email address *
What is your name? *
First, Last - Do you have a preferred name?
Are you 18 years of age or older? *
Patrons must be the age of consent.
What is your phone number? *
Do not include hyphens
What is your preferred language? *
We will do our best to match you with a volunteer that meets your language preference
How many visits per week would you like? *
What are your preferred times of the day to call? *
Please make sure that the number of days matches the number of calls indicated in the previous question.
9AM - 12PM
12PM - 3PM
3PM - 6PM
What kind of call(s) would you like? *
Please make sure the number of calls matches the previous question. Ex. "I want a group chat for my first call and then a one-on-one."
Either option
Not applicable
1st call
2nd call
3rd call
4th call
5th call
6th call
7th call
What are your interests?
List some of your hobbies and interests, to spark conversation!
What is your preferred method of contact? *
Please select as many applicable options as possible
What is your main reason for using this program? *
Do you have any questions that you would like us to contact you about? *
Is there anything that we have not asked yet. If yes, please describe. *
How did you hear about Virtual Visitors?
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