Form Center

2. 
4. First Name (Optional)
5. Last Name (Optional)
7. Membership Price (Please choose one)

   1. Too Low

   1. Too High

   1. Fair
9. Programs (Please choose one)

   1. Poor

   1. Fair

   1. Good

   1. Excellent
11. Classes (Please choose one)

    1. Poor

    1. Fair

    1. Good

    1. Excellent
13. Trips (Please choose one)

    1. Poor

    1. Fair

    1. Good

    1. Excellent
15. Customer Service (Please choose one)

    1. Poor

    1. Fair

    1. Good

    1. Excellent
17. Have you ever requested information, referral, or application assistance, such as Income Tax, Medicare, Senior Tax Freeze, Benefit, Access, VENTRA, Wills Program, Lending Closet, etc., at the NSC?*

    1. Yes

    1. No
19. If you answered "Yes" to the above, please rate your experience.

    1. Poor

    1. Fair

    1. Good

    1. Excellent
21. Overall Niles Senior Center Rating (Please choose one)

    1. Poor

    1. Fair

    1. Good

    1. Excellent
23. Would you recommend us to a friend? (Please choose one)

    1. Yes

    1. No
27. Please share your thoughts on how we can improve your experience.
    (750 characters maximum)
29. Date
    Date
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