Village PDX Becomes Villages NW
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What Do You Want From a Village? A Benefits Survey for Prospective Members
Step 1 of 6
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What benefits or services would you like to have offered by a Village serving your neighborhood?
[Note: some of these services could be provided by volunteers and others would be provided by vendors that have been screened for quality & may offer these services at a discount to Village members]
Daily Living Services - Check as many as you want
Transportation
Home maintenance (ie. replacing light bulbs, routine repairs)
Home repairs (plumbing, electrical, painting)
Housecleaning
Laundry
Gardening /yard work
Shopping
Cooking
Planning meals
Canning/food preserving
Assistance with technology/computer/electronic equipment
Pet care & dog walking
Shoveling snow
Weatherproofing
Housesitting
If you selected Transportation above, what are your most frequent destinations?
If you selected Shopping above, what type?
Other Daily Living Services not listed above
Organized Fitness Activities that you would like to participate in if you remain in your neighborhood as you grow older. Check as many as you want.
Personal trainer
Scheduled exercise program
Yoga/Tai Chi/stretching
Meditation
Walking groups
Biking
Dance classes
Hiking
Golf
Tennis
Skiing
Swimming
Other Organized Fitness Activities not listed above
Personal & Financial Services that you believe will be important to you as you grow older. Check as many as you want.
Bill paying assistance
Balancing checkbook, etc.
Sorting & organizing mail
Insurance & investment advice/educational programs
Tax preparation assistance
Legal assistance
Buying club/village member discounts
Part-time employment
Other Personal & Financial Services not listed above
Organized Activities that you might be interested in (held at neighborhood locations or as scheduled trips.) Check as many as you want.
Volunteering
Companionship
Art/craft classes
Discussion groups
How-to classes
Book clubs
Coffee/tea get-togethers
Intergenerational programs
Lunch groups
Farmers Market trips
Cultural trips (theater, museums, concerts, films)
Dining out groups (restaurants)
Speakers/educational programs
Attending sporting events
Cooking/dinner club (in members’ homes)
Beer brewing group
Wine tasting
Gardening group
Investment club
Card/chess/game groups
Holiday parties
Shopping trips
Other Organized Activities not listed above
Health Assistance Services you might want to have available. Check as many as you want.
Health care/medical advocacy
Filing insurance & Medicare claims
Explaining Medicare plans & health care options
Physical therapy
Massage
Acupuncture
Fall prevention
Nutrition/diet support
Medical/dental referrals
Procuring prescriptions/organizing medications
Home health care
Skilled nursing
Other Health Assistance Services not listed above
How did you hear about this survey?
Are you interested in helping to organize a Village in your neighborhood?
Yes
No
Don't know
Anything we should have asked but didn’t?
If you are completing this form on behalf of someone else, please let us know how to be in contact with you
Your Name
Your relationship to the prospective Village member
Your email
DEMOGRAPHIC INFORMATION
The following demographic information is being collected solely for the purpose of Village planning and development, and will not be shared with any business or commercial ventures. We respect your privacy and will keep your data confidential.
Name - Adult #1
*
Age - Adult #1
*
Name - Adult #2
Age - Adult #2
Email
Address
*
Street Address
City
Alabama
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Arkansas
California
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Connecticut
Delaware
District of Columbia
Florida
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Hawaii
Idaho
Illinois
Indiana
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Louisiana
Maine
Maryland
Massachusetts
Michigan
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Mississippi
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Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
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South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Zip Code
In what neighborhood do you live?
Scroll down to select
-N- North neighborhoods...
Arbor Lodge
Bridgeton
Cathedral Park
East Columbia
Hayden Island
Kenton
Overlook
Piedmont
Portsmouth
St Johns
University Park
-NE- Northeast neighborhoods...
Alameda
Beaumont-Wilshire
Boise
Concordia
Cully
Eliot
Grant Park
Hollywood
Humboldt
Irvington
Kerns
King
Laurelhurst
Lloyd District
Madison South
Montavilla
North Tabor
Rose City Park
Roseway
Sabin
Sullivan's Gulch
Sumner
Sunderland
Vernon
Woodlawn
-SE- Southeast neighborhoods...
Ardenwald-Johnson Creek
Brentwood-Darlington
Brooklyn
Buckman
Creston-Kenilworth
Eastmoreland
Foster-Powell
Hosford-Abernethy
Kerns
Laurelhurst
Montavilla
Mt Scott-Arleta
Mt Tabor
North Tabor
Reed
Richmond
Sellwood-Moreland
South Tabor
Sunnyside
Woodstock
-E- East neighborhoods...
Argay
Centennial
Glenfair
Hazelwood
Lents
Mill Park
Parkrose
Parkrose Heights
Pleasant Valley
Powellhurst-Gilbert
Russell
Wilkes
Woodland Park
-NW- Northwest neighborhoods...
Forest Park
Hillside
Linnton
Northwest District
Northwest Heights
Northwest Industrial
Old Town-Chinatown
Pearl District
-SW- Southwest neighborhoods...
Arlington Heights
Arnold Creek
Ashcreek
Bridlemile
Collins View
Crestwood
Downtown
Far Southwest
Goose Hollow
Hayhurst
Healy Heights
Hillsdale
Homestead
Maplewood
Markham
Marshall Park
Multnomah
South Burlingame
South Portland
Southwest Hills
Sylvan-Highlands
West Portland Park
How many years have you lived in this neighborhood?
How committed are you to staying in this neighborhood as you age?
Totally
Quite a bit
Somewhat
Very little
Not at all
Number of adults in household
*
Own or Rent?
I/We own a house/condominium
I/We rent a house/condominium/apartment
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