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Step One

You will be assisting the Richmond County Aging Services by providing useful information concerning our community and how service to our older adults and their caregivers can be enhanced. When completing this form, it is not necessary that you provide your name or address as anonymous submissions will be accepted. When completed, please press the Submit button, or if you prefer, print it out and mail to the address provided at the end of the survey.
Please complete this survey if you are 55 years or older. For each question, please circle your best answer.
What is your age group?*
1. under 25
2. 25-34
3. 35-44
4. 45-54
5. 55 - 64
6. 65 - 74
7. 75 - 84
8. 85 - 94
9. 95 +
If you are not at least 55 or older, please do not complete this survey.
Do you reside in Richmond County?*
1. Yes
2. No
If No, What county do you currently reside?*
Where do you reside?*
1. Hamlet
2. Rockingham
3. Dobbins Heights
4. Ellerbe
5. Hoffman
6. Norman
7. East Rockingham
8. Cordova
9. Marston
10. Derby
11. Other
Other City or Town not Listed:
What is your gender?*
1. Male
2. Female
What is your race or ethnic background?*
Other, Please specify race
Are you?*
1. Single (never married)
2. Married
3. Divorced
4. Widowed
Continue

Would you like a member of Richmond County Aging Services to contact you?*
1. Yes
2. No
First Name
Last Name
Phone Number
Address
State
Zip Code
Would you like to be added to our E-mail Distribution List?*
You will receive our monthly newsletters and other important information about Aging Services.
1. Yes
2. No, not at this time
Provide you E-mail address here.*

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