Participant Information Form

2. Frederick County Senior Services Division Participant Information Form
4. Personal Information
6. First Name*
7. Last Name*
9. Address*
   Street Address, Apartment/Unit #
11. City*
12. State*
13. Zip*
15. Primary Phone:*
    ###-###-####
16. Cell Phone:
    ###-###-####
17. Work Phone:
    ###-###-####
19. Gender*

    1. Male
    2. Female
20. Email address:
22. Marital Status

    1. Single
    2. Married
23. Birth Date:*
    00/00/0000
25. Emergency Contact Information
27. First Name
28. Last Name
30. Address
    Street Address, Apartment/Unit #
32. City
33. State
34. Zip
36. Primary Phone:
    ###-###-####
37. Secondary Phone:
    ###-###-####
38. Email:
40. Relationship

    1. Daughter/Daughter-In-Law
    2. Grandparent
    3. Husband
    4. Non-Relative
    5. Other Elderly Non-Relative
    6. Other Elderly Relative
    7. Other Relative
    8. Relationship Missing
    9. Son/Son-In-Law
    10. Wife
42. Other Information (Please check all that apply)
44. Please indicate race*

    1. African American
    2. American Indian/Alaskan
    3. Asian
    4. Hawaiian/Pacific Islander
    5. White
    6. Other
    7. 2 or more races
    8. Decline to answer
45. Please indicate ethnicity*

    1. Hispanic
    2. Non-Hispanic
    3. Decline to answer
47. I live alone:*

    1. Yes
    2. No
48. I served in the Military:

    1. Yes
    2. No
49. I am a registered voter:

    1. Yes
    2. No
    3. Need forms
51. Monthly Household Income:

    1. Single, under $1012/month
    2. Single, over $1012/month
    3. Married, under $1372/month
    4. Married, over $1372/month
52. Number in Household
    #
53. Personal Health:

    Check all health conditions that apply

    1. Chronic disease
    2. Physical
    3. Mental health
    4. Developmental/Intellectual
    5. Traumatic brain injury
55. Privacy Policy
    The information you include on this registration form will be used to help improve programs for seniors, and/or determine if you qualify for a program. It may be shared with the Maryland Department of Aging (MDOA). The Frederick County Senior Services Division and the MDOA will not voluntarily share any information that identifies you except with people working for them who need the information to perform their jobs. This includes your name, address, and telephone number. You may refuse to give some or all of the information requested. However, if a program is only for people who meet its qualifications (such as age, income, or health condition), and you choose not to share the facts that show you qualify, you may not be able to take advantage of that program. The Frederick County Senior Services staff can tell you exactly what information is needed to determine if you qualify for a program. You may look at a record that identifies you to ensure the facts are correct. To view your record, you must make your request in writing to Kathy Schey, Director of Frederick County Senior Services, 1440 Taney Avenue, Frederick, MD 21702, or kschey@frederickcountymd.gov, or to Maryland Department of Aging, 301 West Preston Street, Suite 1007, Baltimore, MD 21201.
57. Participant Agreement
    I agree to allow the Frederick County Senior Services staff to make referrals to other agencies as appropriate on my behalf and disclose pertinent information as necessary. I agree to allow representatives of agencies, programs, or services for which I have applied or am currently enrolled to provide pertinent information to representatives of the Senior Services Division. I acknowledge that there are inherent risks and dangers associated with senior center program/s and therefore, I agree to waive and release any and all claims against Frederick County, MD, its officers, employees, and agents for any damages, loss, direct or indirect, or bodily injuries sustained by me as a result of my participation in any Frederick County Senior Services Division Senior Center activity. I agree to allow Frederick County Senior Services to take and utilize photos, slides, and video images for the purpose of promotion and publicizing of the Department's programs, facilities, and/or events. I acknowledge that information provided to the Frederick County Senior Services will be maintained according to confidentiality guidelines established by the Senior Services Division, HIPAA and the Maryland Board of Nursing. I acknowledge I am aware of and agree to observe the senior center guidelines, policies and procedures as posted in the center and on the Division website. I may receive a print copy upon request. I understand that I may revoke my consent to release information, but not retroactive to release of information already made in good faith.
59. By typing my name in the signature box below, I affirm the information submitted is accurate, and I have read and accept the privacy policy and participant agreement statements.
61. Signature:*
62. Date:
    00/00/0000
64. Preferred Participation Locations*

    Check all that apply

    1. Brunswick
    2. Emmitsburg
    3. Frederick
    4. Urbana
    5. Trips
    6. Not Specified
66. Other Information
68. I need more information about:

    Check all that apply

    1. Caregiver Issues and Support
    2. Educational Opportunities
    3. Employment Resources
    4. Food Resources
    5. Financial Assistance / Tax Credits
    6. Health Education
    7. Health Resources
    8. Housing Resources
    9. Legal Resources
    10. Long Term Care
    11. Medicare/Medicaid
    12. Insurance
    13. Physical Fitness Opportunities
    14. Recreation Opportunities
    15. Transportation Resources
    16. Veterans Benefits
    17. Volunteer Opportunities
69. Other Information needed:
71. Nutritional Health
73. How is your Nutritional Health?
    Good nutrition has been identified as a key component of maintaining health and independence as we age. The Nutrition Health Survey is an initiative to identify individuals who may be at nutritional risk and could benefit from resources offered by the Department of Aging and other community agencies.
75. Do you have a dietary influenced illness?

    1. Yes
    2. No
76. Do you eat less than 2 meals per day?

    1. Yes
    2. No
78. Do you have 3 or more alcoholic drinks daily?

    1. Yes
    2. No
79. Do you eat less than 5 servings of fruits, vegetables and dairy products each day?

    1. Yes
    2. No
81. Do you have tooth/mouth problems?

    1. Yes
    2. No
82. Do you lack money for food?

    1. Yes
    2. No
84. Do you usually eat alone?

    1. Yes
    2. No
85. Do you use 3 or more prescription and/or over-the-counter medications daily?

    1. Yes
    2. No
87. Have you had unintentional weight fluctuations of 10 lbs or more in the last six months?

    1. Yes
    2. No
88. Are you unable to shop for/cook/eat food?

    1. Yes
    2. No
90. Count your YES answers

    1. 0-2 Good job!
    2. 3-5 Doing okay, but consider making some changes.
    3. 6-9 Needs improvement. Check with your health care provider.
Leave This Blank:


92. 1. Receive an email copy of this form.
93. Email address

    This field is not part of the form submission.

94. Submit

* indicates a required field