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Virtual Companionship Form
We will do our best to pair you with someone with similar interests. We ask you to stay in contact via email or phone call. If you have any concerns or issues, please call us at 402-522-6394.
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Name
*
Your answer
How would you prefer to stay in contact?
*
Phone call
Email
Both
What is your phone number?
Your answer
What is your email address?
Your answer
How often would you like to be contacted?
Your answer
What times of the day would be best to contact you?
Your answer
Please check all applicable interest categories.
The arts (theater, artwork, dance, etc)
Sports
Nature
Books
Movies/TV
Cooking/baking
Keeping active (working out)
Animals/Pets
Other
If you checked other, please add interest(s)
Your answer
Other notes
Your answer
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