Congregate / Grab & Go Registration
Must be at least 60 years old and a resident of Jefferson County.
Name
*
First Name
Last Name
Gender
*
Please Select
Male
Female
Date of Birth
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
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31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
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1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Race / Nationality
*
Please Select
African American
White / Caucasian
Native American
Pacific Islander
Asian
Hispanic / Latino
Phone Number
*
Please enter a valid phone number.
What is your annual income?
*
Please Select
1 person below $15,060
1 person above $15,060
2 people below $20,440
2 people above $20,440
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Select a meal site near you
*
Please Select
Amsterdam Grab & Go (348 N. Main St, Amsterdam, OH)
Bergholz VFD (724 Monroe St, Bergholz, OH)
1st Westminster (235 N. 4th St, Steubenville, OH)
Hammondsville
Heritage (3010 Johnson Rd, Steubenville, OH)
Pleasant Hill (129 School St, Steubenville, OH)
Prime Time (300 Lovers Ln, Steubenville, OH)
Richmond Site (212 Sugar St, Richmond, OH)
Toronto Site (425 N 5th St, Toronto, OH)
Email
example@example.com
Emergency Contact Information
Emergency Contact Name
*
First Name
Last Name
Relationship to Applicant
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Nutrition
Are you diabetic?
*
Yes
No
Do you have any food allergies?
*
Please Select
Yes
No
List any allergies that you may have.
ADL & IADL's
Activities of Daily Living & Instrumental Activities of Daily Living
Bathing
*
Independent
Mostly Dependent
Totally Dependent
Meal Preparation
*
Independent
Mostly Dependent
Totally Dependent
Dressing
*
Independent
Mostly Dependent
Totally Dependent
Managing Medications
*
Independent
Mostly Dependent
Totally Dependent
Toilet Use
*
Independent
Mostly Dependent
Totally Dependent
Money Management
*
Independent
Mostly Dependent
Totally Dependent
Transfer / Mobility
*
Independent
Mostly Dependent
Totally Dependent
Heavy Housework
*
Independent
Mostly Dependent
Totally Dependent
Eating
*
Dependent
Mostly Dependent
Totally Dependent
Light Housekeeping
*
Independent
Mostly Dependent
Totally Dependent
Walking in home
*
Independent
Mostly Dependent
Totally Dependent
Shopping
*
Independent
Mostly Dependent
Totally Dependent
Transportation
*
Independent
Mostly Dependent
Totally Dependent
Telephone Use
*
Independent
Mostly Dependent
Totally Dependent
Nutritional Risk Form
*
Yes
No
Have you made any eating habit changes due to health reasons?
Do you eat fewer than (2) meals per day?
Do you eat fewer than (5) servings (1/2 cup each) of fruit or vegetables everyday?
Do you eat fewer than (2) servings of dairy products (Milk, Yogurt, Cheese) everyday?
Do you sometimes not have enough money to buy food?
Do you have any trouble eating well due to problems chewing or swallowing?
Do you eat alone most of the time?
Without wanting to have you lost or gained (10) pounds in the last (6) months?
Are you not always physically able to shop, cook, and/or feed yourself (or to get someone to do it for you?
Do you have (3) or more drinks of beer, liquor, or wine almost everyday?
Do you take (3) or more prescription or over the counter drugs per day?
Submit
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