Chemung County Age-Friendly Application

Age-Friendly Chemung County
If you are interested in being designated as an Age-Friendly Business or Organization, please review and complete this form.
To Qualify:

Must be a business or organization located in or providing services in Chemung County. Designation criteria are outlined below.

The Process:
- After completing this form, you will be contacted by a representative of the Age-Friendly Chemung County Coalition.
- The representative will schedule a mutually convenient time to visit your business, which will allow Age-Friendly representatives to see some of your Age-Friendly qualities in action.
- A panel will review your application and the information gathered at the visit.
- If approved, you will receive an Age-Friendly decal to formally designate your business or organization as Age-Friendly. You will also receive an electronic version of the logo.
- Your business or organization will be honored at the Older Americans Month Celebration in May or at the Chemung County Department of Aging and Long Term Care Public Hearing.
Instructions For Filling Out This Form:

To begin, click on each of the tabs below (Business/Organizatiion, Physical Environment etc.) to enter your information. When done, click on the Commitment and Signature tab and sign the form (to the best of your ability). Then click on the Preview/Submit Application tab, click the Preview Answers button, and when satisfied, click the Submit Application button. You will receive a confirmation email of your application for your records.

* = Required Field
Business/Organization
Please Indicate if You Are a Business or Organization:*

BusinessOrganization
Is this Business/Organization Physical, Virtual or Both:

PhysicalVirtualBoth
Business or Organization Name:*
Business/Organization Address:

Street Address

Street Address Line 2

CityState

Zip Code
Contact Name:*

First NameLast Name
Title:
Phone Number
Email:
Website:
If You Have Multiple Locations That You Would Like Designated, How Many Additional Locations Are There?:
ADDITIONAL Locations
2nd Location:
3rd Location:
4th Location:
5th Location:
6th Location:
7th Location:
8th Location:
In each of the following categories, please check off the Age-Friendly
characteristics your business or organization possesses. To receive
Age-Friendly designation, your business or organization must possess
at least 20 of the following characteristics in these sections, including at least two in each category (not including Services Offered).

Any business with a physical location must have at least one wheelchair-accessible entrance to be considered Age-Friendly. Virtual-only businesses will be considered on the categories that apply to them.

Click on each section below to expand it, then click on each characteristic your business or organization possesses.
Physical Environment
Physical Environment:
Physical Environment: (Please select all that apply)*

A wheelchair accessible entrance...Enough parking, parking close to the building, and accessible parking...A drop-off/pick-up area for customers...Low curbs for easy sidewalk access...Sidewalks, hallways and stairways that are clear of obstructions...Aisles within business or organization are wide enough for passing...Easy-to-open or automatic doors...A waiting area with comfortable chairs for all ages, including breastfeeding mothers...Chairs that can be easily moved to where people need to sit...A wheelchair-accessible restroom...Adequate exterior lighting if open after dark...
Sound
Sound: (Please select all that apply)*

Background noise that does not interfere with hearing or taking part in discussions...If you play music, certain music-free hours that won’t interfere with an older adult’s ability to carry on conversations...Clear public announcements spoken at a slow enough pace for easy understanding...No loud music or harsh acoustics...Quiet areas in your business or organization, such as specific tables that can be reserved...Carpets or rugs, hanging tapestries, upholstered furniture, or soundboard walls or partitions that help absorb noise...If you take on a construction project, you will strive to use sound-absorption and reduction measures...Heavy walls and thick windows that keep traffic and outside noise to a minimum...Keeping doors closed to noisier spaces...
Sound:
Customer Service
Customer Service: (Please select all that apply)*

Assistance is available for reaching or accessing items...Employees will offer to read materials aloud or help anyone who appears to be struggling...Audio recordings or Baille in office, room numbers, departments, building directories, elevator call buttons, and panels by the elevator door...Employees trained in first aid response in case of medical emergency...Employees trained to identify someone who needs physical assistance or is being physically or financially abused, with contact info for organizations that can help these individuals...Delivery options for homebound individuals and pick-up options for thoses who have trouble getting around/navigating your business...Breastfeeding mothers are always welcome and respected, and are never asked to stop breastfeeding or cover up more...Accomodations are made for children, such as high chairs and booster seats in restaurants; changing tables in restrooms; and/or books and toys...
Customer service:
Verbal Communication
Verbal Communication: (Please select all that apply)*

Employees that speak in a clear and respectful voice, without overly exaggerating tones, simplifying words, or speaking too loudly to help an older adult hear...Private conversations ensured when necessary...Employee awareness to repeat himself or herself if necessary; an older adult may wish for a question to be repeated, but may be too embarrassed to ask...Employee awareness to get an older adult’s attention before speaking...Employee awareness to lower the pitch of his or her voice when speaking to someone who has difficulty hearing, and to be conscious that words with F, S, K and SH sounds are sometimes particularly difficult...
Verbal Communication:
Visibility
Visibility: (Please select all that apply)*

Large, clear subtitles for videos and other multimedia that is important to your business.Written instructions in addition to verbal instructions for customers...Good lighting, as older adults require three times the light to see as younger people, and well-lit environments allow older eyes to rest...Non-glare lighting, shades on lights, or indirect or filtered lighting...Small direct task lights over areas where reading or other visually demanding tasks are necessary...
Visibility:
Marketing, Design and Web Presence
Marketing, Design and Web Presence: (Please select all that apply)*

Provide discounts and promote products and services of interest to older adults, include older adults in ads, and make sure your ads reach older adults...Package products in a range of sizes...Special senior days or hours during the day devoted to service of older adults...Utilize word of mouth advertising and community bulletin boards...Openly show support of activities and events for older adults...Include an easy-to-find phone number where a caller can talk to a person, not a machine...Use shorter video segments and other media so they will load more quickly on older computers...Include easy-to-find instructions for web users who are less technologically savvy...Include an easy text resize option on your website...Use clean, easy-to-read fonts...Utilize margins and space between lines of text...Avoid using colors that are in close proximity on the color wheel...Design color materials with effective contrast using vivid colors...Use simple designs and avoid patterned backgrounds...
Marketing, Design and Web Presence:
Services Offered
Services Offered: (Please select all that apply)

Outdoor Spaces and Buildings: Clean and safe community centers, parks, or other recreational facilities...Transportation: Public and private transportation options or advocacy for safe streets and roads, bike routes, sidewalks and walking paths...Housing: Safe and affordable housing or home modification assistance that supports aging in the community, and housing that is accessible to transportation or community services...Social Participation: Leisure or social activities...Respect and Social Inclusion: Services that support and respect aging, ethnic and socioeconomic diversity, multigenerational interaction, or caregiver needs...Civic Participation and Employment: Opportunities for employment, education, volunteering and community engagement, regardless of age or disability...Communication and Information: Providing access to libraries, newspapers and newsletters, computers and the Internet, and other information sources to keep older adults connected to their community and family...Community Support and Health Services: Healthcare, homecare or other programs that promote wellness and active aging...
Services Offered:
Other: Please describe:
Comments
Please provide a brief explanation of your business or organization. If you are designated as Age-Friendly, this information will be utilized in the formal presentation of the designation.

You may also use this space for a written explanation of how your business or organization strives to be Age-Friendly.
Comments:
Commitment and Signature
Please state your committment to the Age-Friendly Business or Organization
designation, and the vision of Chemung County as an Age-Friendly
Community, by filling out the section below.

This commitment statement should be signed by your business
or organization President, Executive Director or Chief Executive Officer.
Please Sign (with mouse or finger depending on device you are using). It's OK if the signature does not look exactly like it would on paper:
Please Sign Below:*
Please Enter Your Full Name As Signed Above:*

First NameMiddle InitLast Name
Date:*

MonthDayYear
Date
Title:
Phone Number
Email:*
example@example.com
Preview/Submit Application
Below are examples of the decals that will be provided if your business
or organization is designated as Age-Friendly. If you are a business, you will receive the decal on the left. If you are an organization, you will receive the one on the right. Decals are 3’’W x 5’’H with a white background. The adhesive is located on the back to allow for placement on many different types of possible surfaces, including windows, bulletin boards, signs, etc. You will also receive an electronic version of the logo for marketing purposes.
Click the Preview Answers button and, when satisfied, click the Submit Application button. You will receive a confirmation email of your application for your records.
Email From:
Should be Empty:

Age-Friendly Chemung County

Business/Organization

Physical Environment

Sound

Customer Service

Verbal Communication

Visibility

Marketing, Design and Web Presence

Services Offered

Comments

Commitment and Signature

Preview/Submit Application