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2. What is your age:

   1. <60
   2. <60-64
   3. <65-69
   4. <70-74
   5. <80-84
   6. <85-89
   7. <90+
4. What is your gender?
   In the space above type in your gender.
6. 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:
8. HCH Library's programs
10. Bingo at the Clinton Firehouse
12. VFW or American Legion activities
14. Programs sponsored by Clinton Park and Rec Dept.
16. Walk, jog or bicycle on the trails of fields in the town
18. Programs offered by the Clinton Police Dept.
20. Programs offered by the Estuary Council of Seniors
22. Home meal delivery program
24. Thursday Lunch Cafe at the Clinton Town Hall Annex
26. Shoreline Soup Kitchen meal on Wed. at The United Methodist Church
28. Shoreline Soup Kitchen Pantries
30. Tuesday Shopping Bus for grocery shopping
32. Transportation services for doctor's appointments
34. Services provided by Clinton Social Services
36. Federal and state property tax relief programs
38. Senior programs/services in nearby towns
40. Other
    Please write in any other program not listed above.
42. 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.
44. HCH Library
46. The Estuary Council of Seniors
48. Other
50. What obstacles may prevent you from participationg in programs/services for Clinton Seniors:

    You may select more than one checkbox.

    1. I don't know about programs
    2. I don't have transportation
    3. They are for "old" people
    4. I'm too busy with other things
    5. I'm still working

    1. The activities don't interest me
    2. It is difficult to engage in new activities
    3. The hours are not convenient
    4. I have certain health problems
    5. The programs/services cost too much
52. Other reasons preventing you from participating in services offered by Clinton:
54. If you want to remain in Clinton as you age, what services/programs would you like to see offered to Clinton residents:

    1. Physical activities
    2. Hobbies, games
    3. Day trips
    4. Performance and the Arts
    5. Discussion Groups
    6. Volunteer Activities
56. What other services or programs would like to see in Clinton:
58. Do you prefer daytime or evening services/programs offered in Clinton
60. Do you need/would you use transportation services to these Clinton based services/programs?
62. How do you generally learn or receive information about programs/services:

    1. Email
    2. Snail mail
    3. Flyers at local establishments, Town Hall, Library
    4. Harbor News

    1. Phone Calls
    2. Social Media
    3. Patch
64. Please identify any other way you learn about or receive information about Clinton program/services:
66. What barriers might prevent you from maintaining independent living in your home?
68. What senior alternative housing would you like to see developed in Clinton?
70. What needs of Clinton Seniors are not currenly being addressed by the town or local organizations?
72. Is there anything else we have not addressed that you believe would be important for the Task Force to know and consider in planning future programs and services?
Leave This Blank:


74. 1. Receive an email copy of this form.
75. Email address

    This field is not part of the form submission.

76. Submit

* indicates a required field