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Senior Meals Registration
Valid from July 1, 2026 to June 30, 2027
Meal Site
*
Downtown Oakland Senior Center
Hayward Area Senior Center
Josephine Lum Lodge
Kenneth Aitken Senior Center
Mastick Senior Center
Northgate Terrance
Palo Vista Gardens
Ruggieri Senior Center
San Leandro Senior Center
Are you 60 years old?
*
Yes
No
You can still qualify for our Meal Program if you meet one of the following conditions:
1. My Spouse / Partner is a Spectrum Senior Meals Participant. 2. I am a disabled person under 60 who lives in a housing facility primary occupied by older adults. 3. I am a disabled person under 60 who lives at home and accompanies an older adult participating in the program. 4. I am a volunteer. If you meet any of these conditions, please visit your meal site and fill out a form in person. If you do not meet any of these conditions you can still participate in our lunch program for a flat $18 fee per meal.
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Basic Information
First Name
*
Last Name
*
Birthdate
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Street Address
*
Apt / Unit / Space #
City
*
Zip Code
*
Phone Number
Type
Home
Work
Cell
Other
Email Address
*
Spectrum will periodically send out communications. You have the option to:
Opt out of Emails
Opt out of SMS / Text Messages
Emergency Contact First Name
Emergency Contact Last Name
Emergency Contact Phone Number
Emergency Contact Relationship
Spouse
Son/Daughter
Brother/Sister
Caregiver
Friend
Neighbor
Other
Does anyone else in your household participate in the Senior Meals Program?
*
Yes
No
Name
*
First Name
Last Name
Relationship
*
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Demographic Questions
Your Gender
*
Male
Female
Transgender Female to Male
Transgender Male to Female
Genderqueer/Gender Non-binary
Decline to state
Other
What was your sex at birth?
*
Male
Female
Decline to state
How do you describe your sexual orientation or sexual identity?
*
Straight/heterosexual
Bisexual
Gay/Lesbian/Same-Gender Loving
Questioning/Unsure
Decline to state
Other
Relationship Status?
*
Single (Never Married)
Married
Domestic Partner
Separated
Divorced
Widowed
Decline to State
Are you a U.S. veteran?
*
Yes
No
Is your spouse a U.S. veteran?
*
Yes
No / Not Applicable
Race (check all that apply)
*
Caucasian/White
Hispanic/Latino
African American/Black
American Indian/Alaska Native/Indigenous
Middle Eastern / North African
Asian Indian
Cambodian
Chinese
Filipino
Japanese
Korean
Laotian
Vietnamese
Other Asian
Guamanian
Hawaiian
Samoan
Other Pacific Islander
Other race
Decline to state
Preferred written language
*
English
Spanish
Simplified Chinese
Traditional Chinese
Vietnamese
Japanese
Darsi/Farsi
Tagalog
Translation is needed for literature
Other
Are you the Head of Household?
*
Yes
No
Number of people in your household?
*
1, I live alone
2
3
4 or more
What is your current housing status?
*
Own (outright)
Own (with mortgage)
Rent
Live with others (no cost)
Other
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One Person Household Income
Monthly Income Range (for household size of 1 person)
*
$0 - $1,330
$1,331 - $2,971
$2,972 - $4,950
$4,951 - $5,940
$5,941 - $7,921
$7,922 +
Decline to State
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Two People Household Income
Monthly Income Range (for household size of 2 people)
*
$0 - $1,803
$1,804 - $3,396
$3,397- $5,658
$5,659 - $6,790
$6,791- $9,050
$9,051 +
Decline to State
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Three People Household Income
Monthly Income Range (for household size of 3 people)
*
$0 - $2,277
$2,278 - $3,821
$3,822 - $6,367
$6,368- $7,640
$7,641 - $10,183
$10,184 +
Decline to State
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Four or more People Household Income
Monthly Income Range (for household size of 4 people)
*
$0 - $2,750
$2,751- $4,242
$4,243- $7,071
$7,072- $8,485
$8,486 - $11,313
$11,314 +
Decline to State
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Nutrition Screening Initiative & Digital Signature Collection
Select all the checkboxes that apply to you
*
I have an illness or condition that made me change the kind and/or amount of food I eat
I eat fewer than 2 meals per day
I eat fewer than 2 servings (1/2 cup each) of fruits or vegetables each day. I eat less than 1 serving of milk or dairy products each day.
I regularly consume 3 or more alcoholic beverages each day.
I have trouble biting, chewing, or swallowing and/or 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 3 or more different prescribed or over-the-counter medications a day.
Without wanting to, I have lost or gained 10 pounds in the last 6 months.
I am not always physically able to shop, cook and/or feed myself.
None of these apply to me
Decline to State
Functionally Impaired
*
Eating
Bathing
Toileting
Transferring
Walking
Dressing
Cooking
Shopping
Managing Medications
Managing Money
Using Telephone
Heavy Chores
Light Chores
Transportation
Laundry
None of these apply to me
Decline to State
What type of health insurance coverage do you have?
*
Medi-Cal
Medicare
Other Payment forms
Uninsured / None
Decline to State
Who is your primary health plan provider or network?
*
AARP United Healthcare
Aetna
Alameda Alliance for Health
Alignment Health
Anthem Blue Cross
Asian Health
Bankers Life
Baywell Health
BlueShield of California
Center for Elders' Independence
Chinese Community Health Plan
Cigna Healthcare
Harvard Pilgrim Healthcare
HealthSpring
Hill Physicians
Imperial Health Plan
John Muir Health
Kaiser Permanente
San Francisco Health Network
SCAN Health Plan
Stanford Health Care
State Farm
Sutter Health / Palo Alto Medical Foundation
TriCare
United Healthcare
Veteran's Affairs
Uninsured / None
Decline to State
Other
Signature
*
I certify that I have either completed this form myself or, if I had assistance, I have reviewed it to ensure that the information provided is true and accurate. I agree that my electronic signature is the legal equivalent of my manual handwritten signature.
Submit
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