Dining Site Registration Form

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Client Donation

Dining Site Registration Form

"*" indicates required fields

Agency Name*

Meal Site*

Participant Name*

First Middle Last

Participant Address*

Street Address Address Line 2 City State ZIP Code

Your Email

Your Phone*

Participant Date of Birth

Live Alone

Yes

No

Veteran

Yes

No

Gender

Male

Female

Other

Prefer not to say

No Response/unknown

Sexual Orientation

Straight/Heterosexual

Lesbian

Gay

Bisexual

Prefer Not to Say

Other

No response/Unknown

Do you consider yourself to be transgender or gender non-conforming

Yes

No

Emergency Contact Name

First Last

Emergency Contact Phone

Participant Speaks English

Very Well

Well

Not Well

Not At All

Participant Speaks Other Language in Home?

Yes

No

If so, what language is primary?

Household Size?

1 Person

2 People

3 People

4 or More People

Race

White

Black

Asian

Amindian/Eskimo/Aleut

Hawaiian/Pac Islander

Hispanic?

Yes

No

Multi-Racial

Yes

No

Is annual income below the poverty level?

Yes

No

$13,590 (household of 1) | $18,310 (household of 2)

Nutrition Risk

Select All That Apply

I have an illness or condition that made me change the kind and/or amount of food I eat

I eat fewer than two meals a day

I eat few fruits or vegetables or milk products

I have three (3) or more drinks of beer, liquor, or wine almost every day

I have tooth or mouth problems that make it hard for me to eat

I don't always have enough money to buy the food I need

I eat alone most of the time

I take three (3) or more different prescribed or over the counter drugs a day

Without wanting to, I have lost or gained ten (10) pounds in the last six (6) months

I am not always physically able to shop, cook, and/or feed myself

Staff Use

I understand that the confidential information I am providing on this form will be used for state and federal reporting requirements, program management, quality assurance, public safety and research. No other use of personal identifying information on th is form is intended unless I authorize it or a court orders it.

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Registration Type (All of these clients qualify at the donation rate)

Over 60

Under 60 Volunteer

Under 60 Spouse, Disabled Family Member Living in Same House, or Unpaid Caregiver

Under 60 Disabled living in senior housing where a meal site is located

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