Congregate Meals Form

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Registration

Assessment Date:

Registration- Assessment Form

Required for All Registered Programs

Personal Data (Please Print):

First Name(s)

Middle Initial

Last Name(s)

Birth Date:

Home Phone#

Email

Residential Address

Address (if homeless, write 00000)

City

Zip

Mailing Address:

Check here if Mailing Address is the same

Mailing Address

City

Zip

Title IIIC Eligibility:

Are you age 60 or over?

Yes

No Stop. Do not meet eligibility requirement.

Last 4 digits Social Security# Optional

Emergency Contact:

Name:

Relationship

Phone:#

Living Arrangement:

Lives Alone

Not Alone

Declined/Not Stated

Federal Poverty Level (FPL)/Household of One: $1,330/mo or $15,960 annual

At or below FPL

Above FPL

Declined/Not Stated

Proficient in English?

Yes

No

If no,

Race and /or Ethnicity: (Please check all that apply)

What was your sex at birth?

Male

Female

Declined/Not Stated

What is your gender?( Check only one)

Male

Female

Transgender Female to MaleTransgender

Transgender Male to Female

Genderqueer/ Gender Non-binary

Declined/Not stated

other

if other, Please Specify

How do you describe your sexual orientation or sexual identity?

Straight/Hetrosexual

Bisexual

Gay/Lesbian/Same-Gender Loving

Questioning/Unsure

Declined/Not Stated

Other

if Other, Please Specify

SECTION 2 – Nutritional Assessment and Veteran Status
Registration and Assessment (July 2023-June 2024)
* Required for (IIIC): In-Person Congregate Meals

Center

Date:

Print Last Name:

Print First Name:

User Email(Hidden)

Type of User

Functional: Activities of Daily Living and Instrumental Activities of Daily Living

ADLs:

Eating

1-Independent

3-Some Human help

5-Dependent

Declined/Not Stated

Clear

Dressing

1-independent

3-Some Human Help

5-Dependent

Declined/Not Stated

Clear

Transferring In/out of Bed/Chair

1-Indepenedent

3-Some Human Help

5-Dependent

Declined/Not Stated

Clear

Bathing

1-Independent

3-Some Human Help

5-Dependent

Declined/Not Stated

Clear

Toileting

1-Independent

3-Some Human help

5-Dependent

Declined/Not Stated

Clear

Walking

1-Independent

3- Some Human Help

5- Dependent

Declined/Not Stated

Clear

IADLs:

Light Housework

1-Independent

3-Some Human Help

5-Dependent

Declined/Not Stated

Clear

Shopping

1-Independent

3- Some Human Help

5- Dependent

Declined/Not Stated

Clear

Meal Preparation

1- Independent

3 - Some Human Help

5- Dependent

Declined/Not Stated

Clear

Transportation

1- Independent

3 - Some Human Help

5 - Dependent

Declined/Not Stated

Clear

Medication Management

1 - Independent

3 - Some Human Help

5 - Dependent

Declined/Not Stated

Clear

Money Management

1 - Independent

3 - Some Human Help

5 - Dependent

Declined/Not Stated

Clear

Heavy Housework

1 - Independent

3 - Some Human Help

5 - Dependent

Declined/Not Stated

Clear

Using Telephone

1 - Independent

3 - Some Human Help

5 - Dependent

Declined/Not Stated

Clear

Nutritional Assessment:

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

Yes

No

Declined/Not Stated

Clear

I eat fewer than 2 meals per day.

Yes

No

Declined/Not Stated

Clear

I eat few fruits or vegetables or milk products.

Yes

No

Declined/Not Stated

Clear

I have 3 or more drinks of beer, liquor, or wine almost every day.

Yes

No

Declined/Not Stated

Clear

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

Yes

No

Declined/Not Stated

Clear

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

Yes

No

Declined/Not Stated

Clear

I eat alone most of the time.

Yes

No

Declined/Not Stated

Clear

I take 3 or more different prescribed or over–the-counter drugs a day.

Yes

No

Declined/Not Stated

Clear

Without wanting to, I have lost or gained 10 pounds in the past 6 months.

Yes

No

Declined/Not Stated

Clear

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

Yes

No

Declined/Not Stated

Clear

Veteran Status

Have you ever served in the United States military?

Yes

No

Declined/not stated

Are you the spouse, legal partner, parent, or child of a person who is serving in or who has served in the United States military?

Yes

No

Declined/not stated

If you identify as being military affiliated, check below if: “I consent to this agency and the California Department of Aging transmitting my name, email address, mailing address, and mobile telephone number to the Department of Veterans Affairs only for the purpose of receiving additional information on veterans benefits for which I may be eligible. I understand that this consent is valid for 12 months.”

Yes

No

Email

Contact the California Department of Veterans Affairs (CalVet) to determine eligibility for services and supports at www.calvet.ca.gov or 1-800-952-5626.

Consent

Congregate Meals program must communicate your information to the network of partners and providers to carry out services for you. Services cannot be completed without these exchanges. Congregate Meals program uses your information in the following ways. By signing, you give permission to:

Share your information with the San Joaquin County Senior Nutrition and congregate meals site.
Prepare and submit referrals, as needed, for social services to other programs on your behalf.
Submit your data to California Department of Aging or any other program funder for reporting purposes.
Provide San Joaquin Office of Emergency Services your information in cases of widespread disasters.

Signature:

Chinese

White

American Indian/Alaska Native

Declined to State

Other Pacific Islander

Samoan

Hawaiian

Guamanian

Other Asian

Vietnamese

Laotian

Korean

Japanese

Filipino

Cambodian

Asian Indian

Black or African American

Hispanic or Latino

Middle Eastern or North African

Other Race/Ethnicity

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Congregate Meals Form Version-2

Required for All Registered Programs

Residential Address

Mailing Address:

Title IIIC Eligibility:

Last 4 digits Social Security# Optional

Emergency Contact:

Living Arrangement:

Federal Poverty Level (FPL)/Household of One: $1,330/mo or $15,960 annual

Proficient in English?

Race and /or Ethnicity: (Please check all that apply)

What was your sex at birth?

What is your gender?( Check only one)

How do you describe your sexual orientation or sexual identity?

Functional: Activities of Daily Living and Instrumental Activities of Daily Living

Nutritional Assessment:

Veteran Status