First Name *Last Name *Gender *MaleFemaleDate 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 olderPhone Number *Street Address *Apartment, suite, etcCity *State/Province *ZIP / Postal Code *Mailing Address (if different from home address)Apartment, suite, etcCityState/ProvinceZIP / Postal CodeEmail Address *Ethnicity *Hispanic or LatinoNot Hispanic or LatinoRace *American Indian / Alaskan NativeAsianBlack / African AmericanNative Hawaiian / Other Pacific IslanderNon-Minority (White, Non-Hispanic)White, HispanicOtherDoes the client understand English? *YesNoIf not, which language does the client speak?Do you have a disability that limits activities such as mobility or self-care? *YesNoIs your household income below the poverty level?YesNoEmergency 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? *YesNoAre you a veteran? *YesNoToday's Date *Comment or messageSubmit First Name *Last Name *Gender *MaleFemaleDate 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 olderPhone Number *Street Address *Apartment, suite, etcCity *State/Province *ZIP / Postal Code *Mailing Address (if different from home address)Apartment, suite, etcCityState/ProvinceZIP / Postal CodeEmail Address *Ethnicity *Hispanic or LatinoNot Hispanic or LatinoRace *American Indian / Alaskan NativeAsianBlack / African AmericanNative Hawaiian / Other Pacific IslanderNon-Minority (White, Non-Hispanic)White, HispanicOtherDoes the client understand English? *YesNoIf not, which language does the client speak?Do you have a disability that limits activities such as mobility or self-care? *YesNoIs your household income below the poverty level?YesNoEmergency 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? *YesNoAre you a veteran? *YesNoToday's Date *Comment or messageSubmit