Thank you for your interest in serving on the Advisory Council for the Area Agency on Aging, PSA 2. Please answer all questions with as much detail as necessary and provide your information within the following form. 

If you have any questions, reach out to Kelsey Haus using the contact information below.

Kelsey Haus, Communications and Training Coordinator
khaus@info4seniors.org
937-341-3020

Question Title

* 1. Please fill out contact information.

Question Title

* 2. Birth year

Question Title

* 3. I am a resident of...

Question Title

* 4. If applicable, how long have you been a resident of this county?

Question Title

* 5. I work in ...

Question Title

* 6. Occupation

Question Title

* 7. Employer 

Question Title

* 8. Work Phone

Question Title

* 9. Race

Question Title

* 10. Do you have a disability? 

Question Title

* 11. Do you use or have experience with services funded by the Area Agency on Aging (such as congregate meals, Healthy U workshops, etc.)? 

Question Title

* 12. Are you employed by, or hold financial interest in, an organization, receiving funds from the Area Agency on Aging? 

Question Title

* 13. Please check all that apply to you:

Question Title

* 14. Please describe your experience working with older adults, elderly services programs, senior centers, etc. (emphasize any leadership experience). 

Question Title

* 15. Please list relevant organizations you belong to.

Question Title

* 16. What are your special interests?

0 of 17 answered
 

T