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Mon-Fri: 9am–5pm
(847) 784-6000
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About
Programs & Services
Lifelong Learning
Events & Education
Amenities
Support Us
Blog
Contact
Mon-Fri: 9am–5pm
(847) 784-6000
Join
Donate

About
Programs & Services
Lifelong Learning
Events & Education
Amenities
Support Us
Blog
Contact
Mon-Fri: 9am–5pm
(847) 784-6000
Join
Donate

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HOW Biography/Lifestyle Form

Home » Programs & Services » Memory Care Programs » House of Welcome Adult Day Program » HOW Biography Form

Fill out the form below or, click here to download, fill out, and email to us at: how@nssc.org.
* indicates a required field.

Participant’s Biography/Lifestyle

This information helps us engage participants in conversation and helps in planning activities.

Application Date

Person Completing Application

Relationship

Telephone

First Name

Last Name

Preferred Name / Nickname

Place of birth

Date of Birth

Location of childhood home(s)

Location of adult home(s)

Name of and type of pets (current and past)

Currently daily routine

Social History

Name of grade school

Name of high school

Name of colleges/universities attended, and any degrees earned

Person’s religion and/or spiritual beliefs? Do they belong to a congregation?

Special family traditions, holidays and/or significant foods

Work & Military Experience

Occupation and important jobs

Any notable achievements or special accomplishments

Retirement date

Is the person a veteran

Yes No

Service Branch

When did they serve

Rank responsibilities

How does the person feel about their military service?

Interests, hobbies and social engagement

Hobbies, activities, (former and present). Any special accomplishments:

Is the person:

Introverted Extroverted A mix of both

Comments

Favorite…

Season

Vacation destination

Sport of physical activity

Sports team

Holiday

Genre for books

Genre for movies

Musical instrument

Music genre

Musicians

Food

Restaurant

Snack

Beverage

Family Info

Name of spouse / partner

Living

Yes No

Name of father

Living

Yes No

Name of mother

Living

Yes No

Name of sibling

Living

Yes No

Name of sibling

Living

Yes No

Name of sibling

Living

Yes No

Name of sibling

Living

Yes No

Children's Names (if any)

List children's name(s) and where they live (city & state). One per line.

Grandchildren's Names (if any)

List grandchildren's name(s)

List great grandchildren's name(s)

Other Important Relationsips

Please include other important relationships you’d like us to know about (extended family members, friends, neighbors, coworkers, caregivers, etc.)

Special Memories

Please share important memories about career, family, life events, travel, etc.

Reach Out Today.

Take the first step toward a more enriching life with NSSC. We look forward to welcoming you!

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North Shore Senior Center does not discriminate against any person served, person employed, or person seeking employment based on age, sex, race, color, disability, ethnicity, national origin, genetic information, religious tradition or spiritual practice. If you feel that you have been discriminated against, call the Senior Help Line at 800.252.8966 or 888.206.1327 (TTY).

Funds in whole or in part for our programs are provided by AgeOptions.