Golden Goals Intake Application
Please fill out this application to help us understand your artistic goals and how we can support you. Please be specific in your answers and include as much detail as possible. If the goal request is time-sensitive, please explain why.

If you are assisting an older adult in applying for Golden Goals, please remember that all questions refer to the older adult. 

This application may take about 20 minutes to complete. 
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Full Name *
Date of Birth *
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Address (ex: 123 Main St. Anywhere, State 10000)  *
Phone Number *
Email Address *
Are you 65 years or older? *
What type of art does your goal involve? *
Required
If you selected "Other," please explain. 
Describe your artistic goal (What do you wish to achieve? Please be specific): *
What is the expected finished product of your goal? (Please check all that apply): *
Required
If you selected "Other," please explain. 
If fulfilled, in what ways would this goal significantly impact your life? (Please be specific): *
What has prevented you from fulfilling this goal on your own? (Please be detailed): *
What resources do you currently have to support this goal? (Please check all that apply): *
Required
If you selected "Other," please explain. 
What additional resources or support do you need to complete your goal? (Please check all that apply): *
Required
If you selected "Other," please explain. 
Is there anything else you would like us to know about your goal or yourself?
Electronic Signature (Type your full name to confirm that the information provided is accurate and that your goal meets the eligibility criteria set forth by Golden Goals.) *
Date *
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Submit
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