Form Center

2. Section 1

   Understanding which services you and your family currently use?

4. Do you or your family member(s) currently use the Council on Aging and/or Rec Center

   1. Council on Aging
   2. Rec Department
   3. Neither
6. How regularly do you use the Council on Aging or Rec Buildings

   1. Never
   2. 1-2 times a year
   3. 1-2 times a month
   4. 1-2 times a week
   5. more than 2 times a week

   If multiple members of your family use the facilities, please answer for the most frequent user

8. What services at the center do you/ your family member use regularly?
10. Section 2

    Your priorities and vision for a new intergenerational community center

12. The Town of Billerica is considering a new intergenerational community center which could host a variety of different activities or programs. Some of the options for this center are below. Please rank the seven priorities below for your ideal intergenerational center by putting a number 1-7 in the blanks (1 is highest priority, 7 is lowest priority):
14. Performance and Arts
15. Enrichment programming for seniors
16. Health & community services
17. Club activities, games & socializing
19. Enrichment programming for kids/teens
20. Sports & fitness
21. Community announcements & meetings
23. The following list of activities and programs are all potential uses of the proposed intergenerational center. Of these, which purposes would you or your family member(s) use?

    1. Dance/art/music classes
    2. Attending/participating in performances
    3. Social programming for kids/teens
    4. Educational programming for seniors
    5. Social programming for seniors
    6. Educational programming for seniors
    7. Health services
    8. Study space
    9. Adult daycare

    1. Exercise equipment
    2. Individual sports
    3. Team sports
    4. Casual gathering
    5. Hosting/attending private events
    6. Club meetings
    7. Information/help desk
    8. Hosting/attending community events
25. Is there anything else you'd like to share about your vision for an intergenerational community center? (Other ways you would use the center, programming you would use, etc.)
27. Demographics
29. Gender

    1. Male
    2. Female
    3. Other
31. Age?

    1. Under 19
    2. 20-29
    3. 30-39

    1. 40-49
    2. 50-59
    3. 60-64

    1. 65-69
    2. 70-74
    3. 75+
33. What is your race?

    1. White
    2. Black or African American
    3. American Indian or Alaska Native
    4. Asian
    5. Native Hawaiian or Pacific Islander
    6. Other:
35. Are you of Hispanic or Latinx origin?

    1. Yes
    2. No
37. In which neighborhood do you live?

    1. Center
    2. East Billerica
    3. North Billerica
    4. Nuttings Lake
    5. Pinehurst
    6. West Billerica (Riverside)
    7. Other
39. May we contact you to follow up on these responses? If yes, please include your name and contact information below!
41. Name
43. Phone Number
45. Email
Leave This Blank:


47. 1. Receive an email copy of this form.
48. Email address

    This field is not part of the form submission.

49. Submit

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