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Clinton Senior Task Force Survey

  1. What is your age:

  2. In the space above type in your gender.

  3. Do you use/participate in the programs and services currently available in Clinton.

    If so please specify which service or program within each category in the list below:

  4. Please write in any other program not listed above.

  5. Do you receive information from the following organizations via email, website, snail mail, social media, hard copy or not at all?

    Please indicate yes or no in the space below the organization.

  6. What obstacles may prevent you from participationg in programs/services for Clinton Seniors:

    You may select more than one checkbox.

  7. If you want to remain in Clinton as you age, what services/programs would you like to see offered to Clinton residents:

  8. How do you generally learn or receive information about programs/services:

  9. Leave This Blank:

  10. This field is not part of the form submission.