Needs Assessment

Name*
First Last
Date*
MM slash DD slash YYYY
Center*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Fax
Contact*
Title
Email*
Describe your facility (adult day program, assisted living, etc.):*
How many seniors does your center serve?*
What are your hours of operation? What one hour time slots do you have available for programming?*
Please briefly describe the space you have available in which to conduct workshops. (Carpeted or tile; #tables; participant capacity; sink, etc.):*
How is your center primarily funded?*
Please attach most recent annual report if applicable.
Max. file size: 300 MB.
What are your expectations for AFTA programming?*

Gender