CAPECO - National Aging Program Information Systems Registration Form

CAPECO
721 SE 3rd, Suite D
Pendleton, OR 97801
541-276-5073 | 800-752-1139

All fields marked with an asterisk (*) are required.

Date *

Date

Welcome! We’re glad you’re here. Would you help us by telling us a bit about you? Services are funded in part by the Older Americans Act, a federal program since 1965. Annually we report demographics of participants. All information is confidential - we do not report personal information - only age, gender, race, zip code, poverty, etc.

Section I – Tell us about you

Name *

First Name Middle Name Last Name

Phone Number (Place an 'x' in appropriate box)

Email

example@example.com

Gender

Male Female

Date of birth

Date

Number in household

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Mailing Address (if different from Street Address)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Monthly household income, based on number in household

Ethnicity

Hispanic / Latino Not Hispanic / Latino

Race (select all that apply)

American Indian / Alaska Native Asian Black / African American Native Hawaiian / Other Pacific Islander White Unknown - some other race