Lawrenceville United Senior AdvantAGE Program

1.) By completing this survey, you will be formally registering for the Program. Your information will help us to better identify your needs and requests and will allow us to keep you posted on events and opportunities.
2.) Keep in mind that all provided information will be kept confidential by LU; we will not reveal individual responses to any outside sources.

Contact Information

1.) Name:

This is a required question

2.) Address:

This is a required question

3.) Phone:

This is a required question

4.) Email:

This is a required question

5.) Birthdate

This is a required question

6.) Race

This is a required question

7.) Marital Status

This is a required question

8.) Gender

This is a required question

9.) Date of Registration

This is a required question

Getting to Know You

1.) Are you currently a Lawrenceville United member?

This is a required question

2.) How long have you lived in Lawrenceville?

This is a required question

3.) Do you live by yourself?

This is a required question

4.) How many in your household?

This is a required question

5.) Do you rent or own your house?

This is a required question

6.) Do you currently attend your neighborhood block watch?

Please include the reason for your answer:

This is a required question

7.) What top 3 businesses in Lawrenceville do you support or visit the most often?

This is a required question

8.) Have you or your family attended any recent community events or meetings?

If so, please list the most recent:

This is a required question

9.) Are you a member of the Lawrenceville Healthy Active Center and/or the Lawrenceville Senior Center?

This is a required question

Lawrenceville United will be mailing you additional information regarding the program once you have registered by submitting this form.