-NOMINATION FORM "S-ANTX FOR-SENIORS" -~

Accolade" 0 M E C A. R £

Name of Nominee: -------------------------------------------------------

Nominated by: _

Will this person be spending Christmas alone? __

Have they recently suffered a loss or had a set-back in health? _

Will this person be open to visitors or hesitant? _

Would you ca II this person relig ious? _

Do you know of any special Christmas traditions this person has celebrated in the past?

What else should we know about this person to better serve them and celebrate with themthis Christmas season? --~------------------------------------------~----

What is the physical address of this person? '-- _

What is the phone number of this person? ~ _

May we tell them that yOlJsent us? ~ _

ALL NOMINATIONS MUST BE TURNED IN BY NOVEMBER 30TH•