Name(Required) First Last Schedule & RefreshmentsWould you prefer the morning, afternoon or evening for participation in activities?(Required) Morning Afternoon Evening Do you normally enjoy three meals a day?(Required) Yes No If no, which meals do you prefer? Breakfast Lunch Dinner Do you have any special dietary needs?(Required) Yes No If yes, please describe:What favorite refreshment(s) and snack(s) may we provide in your Buckner Staycation Apartment?(Required)Do you enjoy alcoholic beverages?(Required) Yes No If yes, please note:Would you like to join a resident for lunch or dinner during your stay?(Required) Yes No InterestsBased on the Calendar of Events found in the Community Newsletter, what scheduled activities might interest you? Please select your top three.1 2 3 What do you enjoy doing for fun and/or pastime?(Required)Buckner will host a private tour of our community for you to include apartment model, community spaces and amenities. Are there any areas of the tour you would like to spend additional time visiting?(Required) Yes No If yes, please note:Would you like the opportunity to meet and visit with residents of Buckner?(Required) Yes No OtherDo you have any other special interests and/or requests you would like to share?(Required) Yes No If yes, please note:Do you know anyone currently living at Parkway Place?(Required) Yes No If yes, and you are willing to share their name, please provide: Guest Suite Accommodations Include Full kitchen with, microwave, coffee service with coffee/tea choices Walk-in closet with clothes hangers Shower/bath with towels, soap, tissues and hairdryer Bottled water Other refreshments of choice Snacks for on-the-go Cable television and wireless Internet access Buckner swag itemsCAPTCHA
