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Personal Information

Gender

UCLA 4-Question Loneliness Survey

Please answer the following questions to help us understand your current social situation.

How often do you feel left out?

How often do you feel that you lack companionship?

How often do you feel isolated from others?

How often do you feel lonely?

Interests

Please indicate your interest in the following program activities:

Check-in phone callsMeeting in-person at a coffee shop

Group events

Please tell us about your hobbies and interests. This information will help us connect you with other members who share similar passions.

Membership Details

Emergency Contact Information

Terms and Conditions

I agree to abide by the rules and guidelines of the program.

Yes

I understand that the monthly membership fee is $10.00, which is waived for the first year.

Yes

I certify that the information provided in this application is accurate and complete.

Yes

I agree to a general background check

Yes

I agree to become a member

We look forward to welcoming you to our community!

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