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Older American's Month FREE System Sweepstakes
Nominate a Special Senior today and enter to win a FREE Medical Alert System for 6 Months!*
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1.
What is your name?
(Required.)
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2.
What is the name of the person you are nominating?
(Required.)
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3.
What is your relation to the nominee?
(Required.)
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4.
How old is the nominee?
(Required.)
65-70
70-75
75-80
80+
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5.
What is the nominee’s current living situation?
(Required.)
Lives alone
Lives with a loved one
Lives in assisted living
Other
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6.
Has this senior ever experienced a fall?
(Required.)
Yes
No
I’m not sure
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7.
How has this senior impacted you or his/her community?
(Required.)
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8.
What is your favorite trait about your nominee?
(Required.)
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9.
Is your nominee on a fixed income?
(Required.)
Yes
No
I’m not sure
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10.
What is your email address?
(Required.)
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11.
What is the best number to reach you?
(Required.)
Current Progress,
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