BUCKS COUNTY AREA AGENCY ON AGING CENTER REGISTRANT DATA SHEET

BUCKS COUNTY AREA AGENCY ON AGING CENTER REGISTRANT DATA SHEET
Middletown Senior Citizens Center
DATE*

MonthDayYear
Date
CHECK ALL THAT APPLY*

CENTER VISITLUNCHBC TRANSPORT
First*
Middle Initial
Last*
GENDER*

MALEFEMALE
ADDRESS*
Town*
State*
Zip*
County*
Township/Borough*
Mailing Address if Different:
Home Phone #*
Please enter a valid phone number.
Cell Phone #*
Please enter a valid phone number.
TEXTING CAPABILITY*

YESNO
EMAIL ADDRESS*
example@example.com
DATE OF BIRTH*

MonthDayYear
Date
SOCIAL SECURITY #: (The BCAAA requires the office to request your Social Security Number when you become a member. However, providing your SSN here is optional. If you prefer, you can stop by the office and provide it in person.)
VETERAN*

YESNO
MARITAL STATUS*

DIVORCEMARRIEDSEPARATEDSINGLEWIDOWED
LIVING SITUATION*

ALONEWITH SPOUSEWITH OTHER FAMILY MEMBER
EMERGENCY CONTACT NAME*
EMERGENCY CONTACT ADDRESS*
EMERGENCY CONTACT PHONE #*
EMERGENCY CONTACT RELATIONSHIP*
UNMARRIED WITH ANNUAL INCOME OF $15,650 OR LESS*

YESNON/A
HUSBAND AND WIFE ANNUAL INCOME COMBINED OF $21,150 OR LESS*

YESNON/A
COMPLETE "BOTH" ETHNICITY AND ETHNIC RACE:
ETHNICITY:*

HISPANIC/LATINONOT HISPANIC/LATINO
ETHNIC RACE*

AMERICAN INDIAN/ALASKANASIANBLACK/AFRICAN AMERICANNATIVE HAWAIIAN/OTHER PACIFIC ISLANDERNON-MINORITY (WHITE OR NON-HISPANIC)WHITE HISPANICOTHER
NUTRITION INFORMATION
TOTAL YOUR NUTRITION SCORE USING THE ABOVE CHART *
A score of 0-2

Good! Recheck your nutritional score in 6 months.

A score of 3-5

You are at moderate nutritional risk. See what can be done to improve your eating habits and lifestyle. Your Office on Aging, Senior Nutrition Program, Senior Citizen Center, or Health Department can help. Recheck your nutritional score in 3 months.

A score of 6 or More

You are at high nutritional risk. Bring this checklist the next time you see your doctor, dietitian, or other qualified health or social services professional. Talk with them about any problems you may have. Ask for help to improve your nutritional health.
NUTRITIONAL RISK SCORE 6 OR HIGHER:*

YESNO
Should be Empty:

BUCKS COUNTY AREA AGENCY ON AGING CENTER REGISTRANT DATA SHEET

COMPLETE "BOTH" ETHNICITY AND ETHNIC RACE:

NUTRITION INFORMATION