First Name *

Last Name *

Gender *MaleFemale

Date of Birth *

Age Verification Documentation *Driver's LicenseOtherSelf-Declared (sign Age Affidavit below)

Age Affidavit: I declare that I am 60 years of age or older

Phone Number *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Mailing Address (if different from home address)

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Email Address *

Ethnicity *Hispanic or LatinoNot Hispanic or Latino

Race *American Indian / Alaskan NativeAsianBlack / African AmericanNative Hawaiian / Other Pacific IslanderNon-Minority (White, Non-Hispanic)White, HispanicOther

Does the client understand English? *YesNo

If not, which language does the client speak?

Do you have a disability that limits activities such as mobility or self-care? *YesNo

Is your household income below the poverty level?YesNo

Emergency Contact *

Emergency Contact Phone *

I understand that the center/site has a grievance procedure that will tell me how to lodge a complaint in the event that I feel I am being discriminated against due to my race, creed, color, sex, age, or national origin. I understand that the information on this form may be used in statistical reports and I hereby give my permission to use the information collected about me if it does not identify me personally by name. *

Do you live alone? *YesNo

Are you a veteran? *YesNo

Today's Date *

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