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Senior Survey

Please complete this survey and update your contact information, so I am better able to understand your concerns and keep you informed about community events and state-related news. If you’d like to fill out a hard copy of the survey, please call my office at 717-244-9232 and we will mail one to you.

First Name

Last Name

Phone

Email Address

Address

City

State

Zip Code(5-Digit)

Are you a Veteran?

Yes No

Are you a Widow/Widower of a Veteran

Yes No

Communication and Information

Can you easily access information that you need about your community?

Yes No

What is the best way to get information to you?

Social and Civic Engagement

What are your favorite activities?

How often do you visit friends and family?

Are you willing to mentor and teach others?

Yes No

If so, please explain.

What are you interested in learning about? Please explain.

Are you willing to volunteer in your community?

Yes No

Housing

Do you use a cane, walker or wheelchair?

Yes No

If so, does your house or apartment have the needed accessibility improvements like ramps, bars, etc.?

Have you been able to do general upkeep around your house or apartment?

Yes No

Have you ever used the Whole Home Repair program?

Yes No

Would you benefit from home care or home health care?

Yes No

Senior Center Participation

Have you utilized any of the following senior center services during the last 6 months? Check all that apply.

Meals Transportation Activities Classes Social Events None of the Above

Concerns

What are the top three concerns you have as you age? Please explain them below.

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Keep up-to-date on the latest legislative and community news. Your email address will be used strictly for legislative purposes.

Email*

ZIP Code

Office Locations

Red Lion Office

100 Redco Ave.
Red Lion, PA 17356
717-244-9232
Mon-Thurs 8:30 a.m. to 4:30 p.m.
Fri 8:30 a.m. to 2:30 p.m.

Main Capitol

410 Irvis Office Building
PO Box 202094
Harrisburg, PA 17120-2094
717-783-6426

© 2025 PA House Republican Caucus. Terms of use

Home
About
- Bio
Newsroom
Legislation
- Sponsored Legislation
Events
94th District
- District Map
- York Co. Roadwork Updates
Resources
Contact