GOLDEN BEAR SURVEY

Name *

First Name

Last Name

Phone *

(###)

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In the last 6 months, which of the following facilities or activities have you attended? (select all that apply) *

Lounge Hours

Rec Center

Pool (excluding aerobics class)

Exercise Classes

None of the Above

Please select your areas of interest for future Golden Bear programming. (select all that apply) *

Volunteer opportunities at SSU

Education sessions / Learning new skills

Social Activities

None of the Above

How do you receive communications about the Golden Bear program? (select all that apply) *

Email

Facebook

Mailed newsletter

Other

None of the Above

Name

First Name

Last Name

Phone

(###)

###

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Emergency Contact

First Name

Last Name

Emergency Contact Phone

(###)

###

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Primary Doctor

First Name

Last Name

Primary Doctor Phone

(###)

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