Center for Healthy Aging Survey
Name
First Name
Last Name
Year of Birth
Gender
Center for Healthy Aging you attend or would be interested in attending:
Clinton County Community Center, 124 E. Walnut Street, Lock Haven
George C. Meck, 50 Fitness Lane, Suite 2, Muncy
Jersey Shore, 641 Cemetery Street, Jersey Shore
Lincoln Center, 2138 Lincoln Street, Williamsport
Loyalsock, 1607 Four Mile Drive, Williamsport
Mill Hall, 9 Peale Avenue, Mill Hall
Renovo, 415 Fourth Street, Renovo
RiverWalk Center, 423 E. Central Ave, South Williamsport
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Please check how your family would prefer to be notified about STEP programs and activities.
Sun Gazette
Lock Haven Express
Webb Weekly
Email
Flyers in public places
Social media (Facebook, Twitter)
Television or radio
Word of mouth
Other
Email
example@example.com
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Areas of Emphasis
Exercise/dance/movement
Please indicate your interest in the following activities and programs that we could provide for adults 60+ years of age.
Rows
Have done
Currently do
Interested in doing
Use Your Noodle
Zumba
Yoga
Tai Chi (various)
Line dancing
Square dancing
Ballroom Dancing
Are there other exercise/dance/movement activities you would be interested in doing?
Yes
No
Please list them here.
Best time for the activities above:
Rows
8AM-10AM
10AM-12N
12N-2PM
2PM-4PM
4PM-6PM
6PM-8PM
Monday
Tuesday
Wednesday
Thursday
Friday
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Areas of Emphasis
Music
Please indicate your interest in the following activities and programs that we could provide for adults 60+ years of age.
Rows
Have done
Currently do
Interested in doing
Singing/karaoke
Playing instrument
Are there other music activities you would be interested in doing?
Yes
No
Please list them here.
Best time for the activities above:
Rows
8AM-10AM
10AM-12N
12N-2PM
2PM-4PM
4PM-6PM
6PM-8PM
Monday
Tuesday
Wednesday
Thursday
Friday
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Areas of Emphasis
Arts and Crafts
Please indicate your interest in the following activities and programs that we could provide for adults 60+ years of age.
Rows
Have done
Currently do
Interested in doing
Painting/drawing
Knitting
Sewing
Crocheting
Weaving
Quilting
Woodworking
Jewelry making
Photography
Are there other arts and crafts activities you would be interested in doing?
Yes
No
Please list them here.
Best time for the activities above:
Rows
8AM-10AM
10AM-12N
12N-2PM
2PM-4PM
4PM-6PM
6PM-8PM
Monday
Tuesday
Wednesday
Thursday
Friday
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Areas of Emphasis
Table Games
Please indicate your interest in the following activities and programs that we could provide for adults 60+ years of age.
Rows
Have done
Currently do
Interested in doing
Cards
Checkers
Chess
Dominoes
Scrabble
Puzzle
BIngo
Board games
Dice games
Are there specific board games you are interested in?
Yes
No
Please list them here.
Are there other table games you would be interested in playing?
Yes
No
Please list them here.
Best time for the activities above:
Rows
8AM-10AM
10AM-12N
12N-2PM
2PM-4PM
4PM-6PM
6PM-8PM
Monday
Tuesday
Wednesday
Thursday
Friday
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Areas of Emphasis
Outdoor leisure/social
Please indicate your interest in the following activities and programs that we could provide for adults 60+ years of age.
Rows
Have done
Currently do
Interested in doing
Walking
Gardening
Bocce
Bicycling
Lawn games
Nature study
Are there other outdoor leisure/social activities you would be interested in doing?
Yes
No
Please list them here.
Best time for the activities above:
Rows
8AM-10AM
10AM-12N
12N-2PM
2PM-4PM
4PM-6PM
6PM-8PM
Monday
Tuesday
Wednesday
Thursday
Friday
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Areas of Emphasis
Clubs
Please indicate your interest in the following activities and programs that we could provide for adults 60+ years of age.
Rows
Have done
Currently do
Interested in doing
Skiing
Kayaking/canoeing
Bird watching
Bible study
Motorcycle
Collectors clubs (dolls, coins, stamps, etc.)
Are there other clubs you would be interested in doing?
Yes
No
Please list them here.
Best time for the activities above:
Rows
8AM-10AM
10AM-12N
12N-2PM
2PM-4PM
4PM-6PM
6PM-8PM
Monday
Tuesday
Wednesday
Thursday
Friday
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Areas of Emphasis
Continuing Education
Please indicate your interest in the following activities and programs that we could provide for adults 60+ years of age.
Rows
Have done
Currently do
Interested in doing
Technology (phones, tablets, etc.)
Computers
Learn a language
Are there other continuing education subjects you would be interested in exploring?
Yes
No
Please list them here.
Best time for the activities above:
Rows
8AM-10AM
10AM-12N
12N-2PM
2PM-4PM
4PM-6PM
6PM-8PM
Monday
Tuesday
Wednesday
Thursday
Friday
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Areas of Emphasis
Evidence-based Programs
Please indicate your interest in the following activities and programs that we could provide for adults 60+ years of age.
Rows
Have done
Currently do
Interested in doing
Tai Chi for arthritis and fall prevention
Walk With Ease
Chronic disease self-management
Diabetes self-management
Healthy Steps for Older Adults (fall prevention)
Health Steps in Motion (exercise, balance, strength)
Dining with Diabetes
Are there other evidence-based programs you would be interested in exploring?
Yes
No
Please list them here.
Best time for the activities above:
Rows
8AM-10AM
10AM-12N
12N-2PM
2PM-4PM
4PM-6PM
6PM-8PM
Monday
Tuesday
Wednesday
Thursday
Friday
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Bus Trips
Please indicate your interest in the following activities and programs that we could provide for adults 60+ years of age.
Rows
Have done
Currently do
Interested in doing
Historical
Sporting Events
Museums/tours
Plays
Casino
Zoo
Mystery trips
Shopping
Dinner theater
Are there other bus trips you would like to take?
Yes
No
Please list them here.
Are there other days trips (three hours or less one way) you would like to take?
Yes
No
Please list them here.
Are there overnight trips you would like to take?
Yes
No
Please list them here.
Are there multiple night trips you would like to take?
Yes
No
Please list them here.
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Volunteering
Please indicate your interest/experience volunteering with the STEP Office of Aging.
Type a question
Rows
Have done
Currently do
Interested in doing
Meals on Wheels
Kitchen volunteer
Clean-up
Activity leader
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