Congregate Meal Program Registration Site:__________________________
Please complete this form to the best of your ability. Staff:________________________
Contact Date
AAA Region
Eligibility Category (Check one):
Client Spouse Volunteer
Caregiver Disabled under 60
- -
Section A. Basic Demographics
Last Name:
First Name:
Middle Initial:
Lives in Rural Area (mark one):
Gender: Female Male
Date of Birth:
/ /
Address #2:
Zip Code:
Home Phone:
( )
Mobile Phone:
( )
Work Phone:
( )
Section B. Social History
Race (Circle one):
American Indian/Alaskan Asian
White Hispanic White not Hispanic
2 or More Races Black/African American
Native Hawaiian/Pacific Islander Other
Ethnicity (Circle one)
Hispanic or Latino
Household Size (Circle One): I live alone. I live with others.
Section C. Financial
I live alone……..and my monthly income is between (circle one)
$1,041/month or less $1,042- $1,561/month $1,562-$2,082/month More than $2,083/month
I live with my spouse……..and our monthly income is between (circle one)
$1,409/month or less $1,410-$2,114/month $2,115-$2,818/month More than $2,819/month
Section D. Contacts
Emergency Phone:
( )
Emergency Contact Name
Emergency Contact
Section E. Nutrition Risk Assessment
Are there times when you don’t have enough money to
buy the food you need?
Yes No
Do you eat alone most of the time?
Yes No
Do you take 3 or more prescribed or over-the-counter
drugs each day?
Yes No
Have you lost or gained 10 pounds in the last 6 months
without wanting to?
Yes No
Are there times when you are not physically able to
shop, cook or feed yourself?
Yes No
Section F. Use of Information
I understand that the information I am providing on this form is for registration purposes. The information will be
used by the U.S. Health and Human Services Administration for Community Living (ACL), the Minnesota Board
on Aging (MBA) and the local Area Agency on Aging, to create statistical reports. ACL, MBA and/or its
assignees may use this information to conduct a study and/or survey of this service. In addition, information
provided here, may be used by other service providers to help identify other services from which I may benefit,
such as follow up to the Nutrition Risk Assessment. This information will not be released to anyone other than
the above mentioned parties in a way that will identify me as an individual unless I sign a separate consent for that
Today’s Date:_____________________________________
MBA 2/19
click to sign
click to edit