a division of  

NEW TSN APPLICATION FORM

FACILITY DIRECTOR:  Complete this form and return completed application by fax to the TSN fax number above (OR return by mail in the enclosed postage paid return envelope).  If the facility qualifies for TSN membership, we will contact you and subsequently send you a complete Membership Agreement.

Facility Name:_______________________________________________________________________

Facility Street Address (no P.O. Boxes please):______________________________________________

City:___________________________________________ State:____________ Zip:_______________

Email:__________________________________________ Website: www._______________________

Name:_______________________________  Title: ________________Phone: (____) ____-________ Fax: (____) ____-_____ Days & Hours Facility is Open (office hours if residential)___________________

Urbanality: rUrban (within 5 miles of Major City)    rSuburban (5-20 miles of Major City)                                                     rExurban (20- 50 Miles of Major City)  rRural

FACILITY PROFILE:

Check type of facility:   rSenior Activity Center  rCommunity Center with Senior Programming

                                    rYMCA or rYWCA with Senior Program  rOasis Site

                                    rHospital Health Program for Seniors  rSenior Clubs

                                    rSenior Residence – Indicate Specific Type Below

rRetirement Community  rIndependent Living  rContinuing Care Ret. Comm.

                                    rOther Type – please specify:________________________________________

MEMBERSHIP PROFILE: 

Please provide COUNTS based on mature adults age 50+ that participate, or reside at your facility (Please include attendees/residents in activities, classes, dances, meals, club meetings, etc.)

Please provide below an estimate, by percentage, the ethnic background of your members/attendees or residents.  This will enable us to provide appropriate materials for your site.

Caucasian: ______________   African-American: ____________________  Asian: ________________

Hispanic/Spanish Speaking:___________ Native American: _______________ Other: ____________

Please indicate which best describes the socio-economic profile of your members/attendees or residents (check one box)

            rAbove Average Income  rAverage Income  rLower Income  rMix of All Income Levels

Please indicate which best describes the activity level of the majority of your members/attendees or residents (check one box)

            rBusy, active and “on-the-go”  rTakes part in some activities  rRarely participates  rAll Types

ACTIVITY PROFILE:

Please check off ALL regularly scheduled activities/program conducted or offered at the facility:

rCrafts (Arts classes, etc.)      rDance                       rPool/Billards             rCards (Bridge, etc.)

r Investment Club/Meetings   rBingo                        rComputer Training              

rExercise Classes                   rFitness Center           rExercise Equipment  rSwimming (on-site)

rOTHER CLASSES/PROGRAMS: ______________________________________________________

OTHER FACILITY CHARACTERISTICS AND SERVICES:

Please check off ALL other services offered at the facility that apply:

rComputer Lab for Seniors’ use

rServe Lunch Daily                rFood Cafe                rSubsidized Meal Site

rOn-site RN                           rFull-time RN             rPart-time RN

rRegular Health Screenings→            rHearing                     rVision                       rDiabetes/Blood Sugar

                          (check the types)  rBlood Pressure         rCholesterol               rOther:___________________

rOTHER CHARACTERISTICS/SERVICES: ______________________________________________

TSN SERVICES – Please indicate which programs your facility would like to receive from TSN (check all that apply):

rYes, our facility is interested in TSN’s FREE Wall/Bulletin Board Program and has wall space to accommodate this unit. (The board is 5 ½’ wide x 4 ½’ high, and is a custom-built unit made exclusively for TSN. The unit houses TSN’s bi-monthly wall magazine, entitled The Senior Network Report, a four-color news magazine written exclusively for mature adults.  The TSN board must be installed in a high-traffic location of the facility, such as a hallway, dining area, activity room, etc.) Note: Senior Facilities must be able to accommodate the FREE Wallboard Unit in order to obtain TSN membership.

rIn what high traffic location could the TSN Wall Magazine/Bulletin Board unit be installed if your application is approved for membership?___________________________________________________________________________

rFREE TSN programs available on an optional basis (TSN Members are given first priority for our additional free programs):

            rFREE Video Seminar Kits – please indicate if your facility has access to: rTV rVCR rDVD Player

            rFREE Physician Led Seminars

rFREE Health Screenings

rFREE Product Samples – If so, any restrictions? (i.e. cannot distribute OTCs)

rYes, my facility would be interested in Spanish materials if available.

Thank you!  TSN will contact you directly to discuss your membership application, and we look forward to working with you!!!

Print Name:_______________________________    Your Title:________________________________

Signed: __________________________________    Date:_________/________________/_____________