Clarksville Montgomery County Ajax Turner

Clarksville Montgomery County Ajax Turner

Senior Citizen’s Center

PARTICIPANT REGISTRATION FORMID#______

Name:______

(Last)(First)(M.I.) (Maiden Name)

Also known as(nickname): ______Home Number: (_____) ______-______

Work Number: (_____) ______-______Cell Number: (_____) ______-______

Male_____ Female _____ MemberDate of Birth: _____/_____/______

Associate Member Date of Birth: _____/______/______

Social Security # _XX_ _XX_ (______) (MANDATORY LAST 4 NUMBERS NEEDED)

If Married Name of Spouse: ______

Residential Address: ______

City/ Town: ______County: ______

State: ______Zip Code: ______City Resident: Yes ___ No ___

Mailing Address: ______

City/ Town:______County:______

State: ______Zip Code: ______City Resident: Yes ___ No ___

Would you like to receive our newsletter? By mail _____By email ______

My E- Mail address is: ______

EMERGENCY CONTACT INFORMATION:

Name: ______Relationship: ______

Telephone: (______) ______-______(_____) ______-______(_____) ______-______

Home Work Cell

Address: ______

Primary Physician:______Telephone: ______

What is your race or ethnic background?

_____ America Indian/ Native American_____ Asian

_____ Black/ African American_____ Hawaiian/ Other Pacific Islander

_____ White, Non-Hispanic_____ Hispanic or Latino

_____ Other (Specify) ______Unknown

do you understand English? ___ Yes ___ NoIf not, which language? ______

OVER

You have authorized release of information to compile data or in case of emergency needs? Y_____ N_____

Do you have a disability that limits activities such as mobility or self care? Y_____ N_____

What? ______

Do you have allergies? ___ If yes, please explain: ______

Are you on any prescription medication? ___ If yes, please list: ______

______

______

Including yourself how many people live in your home? ______

This information is requested so the Center can report cumulative figures on people served to the federal and state governments on persons served, it will in no way reflect on individuals, and will go no farther than the local center.

Check household size/ monthly income:

_____ 1 person in household and a monthlyincome of $ 850 or less

_____ 2 people in household and a monthlyincome of less than $ 1,140

_____ 3 people in household and a monthlyincome of less than $1,430

_____ 4 people in household and a monthlyincome of less than $1,720

______people in household and an income Above $2,010

Services Requested:

_____1. Personal Care _____ 9. Assisted Transportation (Escort)

_____2. Homemaker_____10. Transportation

_____3. Chore Service_____11. Legal Assistance

_____4. Meals-Home Delivered_____12. Nutrition Education

_____5. Adult Day/Adult Day Health_____13. Information & Assistance

_____6. Case Management_____14. Outreach/Client Finding

_____7. Meals-Congregate_____15. Other:______

_____8. Nutrition Counseling______

Grievance Procedure: I understand that if I have a serious complaint about not receiving adequate service from the Clarksville Montgomery County Ajax Turner Senior Citizen’s Center, I have the right to complain to the proper authorities with no penalty to me.

Age Declaration: As a member I declare that I am 55 years of age or older and that my date of birth, noted on page one is correct to the best of my knowledge. As an associate member I declare that I am between 45 and 55 years of age.

Release of Information: I understand that the information collected 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.

Authorization for Referral: I give my permission for Clarksville Montgomery County Ajax Turner Senior Citizen’s Center to contact agencies or persons on my behalf and to release only such information to them as may be needed to determine the level and type of services that I may need. I also grant permission to the receiving agencies to report back regarding services that I may or may not receive or any additional information that may significantly reflect on my need for services.

Client Agreement: By my signature, I affirm that I have read, or have had explained to me, the above statements. The telephone number I need for complaints has been left with me, and I do give the authorization necessary for proper release of information.

Signatures

This form is not complete without your signature and the date…

Date:______Participant: ______

Date:______Participant: ______