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By requesting a FREE copy of one of our magazines, you will release your personal contact information to the professionals that specialize in the areas for which you requested more information, unless you request to not be directly contacted (in Section 2, below).

The professionals that are affiliated with us will assist you in providing answers to your questions and solutions to your special needs.

Please note: We will not sell or release your e-mail address or personal contact information. Our only intent is to assist you in receiving the information that you have specifically requested.

Striped Rock, LLC, is fully committed to safeguarding your personal information and privacy online whenever you use any of our Web sites, which includes all Web sites linked to stripedrock.org or any links with our Web partners. We do not control the privacy policies for the links and advertisements to other Web sites that are operated by other companies, persons, organizations, or entities.

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Section 1 (you must check/complete at least one option)

I need more information for:

Greater Charlotte, North Carolina Area, All For Seniors
Covering: Anson, Cabarrus, Clevelend, Gaston, Iredell, Lincoln, Mecklenburg, Rowan, Stanley, and Union Counties, North Carolina; and Lancaster and York Counties, South Carolina

Upstate South Carolina, All About Seniors
Covering: Anderson, Cherokee, Greenville, Greenwood, Laurens, Pickens, Oconee, Union, and Spartanburg Counties, South Carolina

Other Area(s):
City: State:

City: State:

Section 2 (*marked fields are required)

*I need more information for:

Myself
My Parent
Another Relative
A Friend
A Caregiver
Other

*Your Name:

*Your Street Address:

*Your City:

*Your State: *Your ZIP:

Your Home Phone Number:

Other Phone Number:

Your E-mail Address:

*How and when would you like to be contacted (check/complete at least one)?

I do not wish to be contacted directly
By Phone (Preferred Time to Call )
By Mail
By E-Mail

*I need more information because I …:

Am Considering Moving
Need Assistance at Home
Need General Help Making Decisions
Need information to help take care of a senior

Section 3 (Optional, select up to three categories of more specific information) Adult Day Care
Alzheimer’s/Dementia Care
Auction Information
Behavioral Health
Caregiver Support & Elder Support & Protection
Consumer Fraud Info
Disability Services
Elder Law, Legal Guidance
Financial Services
Funeral Arrangement Information
Funeral Planning Assistance & Questions
Geriatric Care Management
Home Care Assistance
Home Mobility & Accessibility
Hospice Information
Housing Information
    Active Adult
    Assisted Living
    Continuing Care Retirement
    Housing Placement Referral Services
    Housing Related Services
    Independent Living (Apartments)
    Reverse Mortgage Information
    Senior Real Estate Specialist (A Local Realtor Specialist)
    Skilled Care/Nursing Home
    Subsidized & Affordable Senior Housing
Insurance Information
Long-term Care
Meals & Nutrition
Medical Supplies & Equipment
Medical Healthcare & Rehabilitation Facilities
Medicare Supplement Insurance
Medication Assistance
Prevention & Wellness
Rehabilitation
Senior Centers, Associations, and Societies
Transportation Assistance
Veteran Information
Other:

Section 4 (Optional, other comments, questions, or assistance needed)
Your Comments/Questions:

Section 5 (Annual subscriptions)

If you would like an annual subscription to one of our magazines, please mail a check in the amount of $10, payable to Striped Rock to:

Mail To:
Striped Rock
401 Hawthorne Lane
Suite 110-127
Charlotte, NC 28204

Once your payment is received, we will mail you the next three editions, over the next year, of the magazine of your choice.

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