MAG Form

Today's Date:

MonthDayYear

Name:

First NameLast Name

Gender:

Date of Birth:

MonthDayYear

Age:

Phone Number:

Please enter a valid phone numberFormat: (000) 000-0000.

Emergency Contact Name & Phone:

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Current Living Arrangement:

Persons in Family/Household:

Length at Current Residence:

Email:

example@example.com

Ethnicity:

Race:

Marital Status:

Are you interested in attending Spanish Fork's 60+ Lunches regularly? Mondays and Thursdays at 12PM at the FitCity Center in the Community Rooms.

Which days of the week do you plan on attending?

Are you a diabetic?

Do you require dietary accommodations?

If yes, please list:

NOTE: Food accommodations here in Spanish Fork City are a alternative meal of a garden salad. Please call 801-798-5015 if you are interested in ordering an alternative meal.

Rows	Not Satisfied	Somewhat Satisfied	Satisfied	Any thoughts?
Service Quality
Cleanliness
Responsiveness
Friendliness