Fillable ELDER INTAKE FORM PLEASE PRINT CLEARLY (Delaware Nation)

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ELDER INTAKE FORM PLEASE PRINT CLEARLY (Delaware Nation)

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ELDER INTAKE FORM
PLEASE PRINT CLEARLY
TODAY’S DATE________________________
TRIBAL AFFILIATION_____________________________ TRIBAL ROLL #__________________
LAST NAME_________________________ FIRST NAME__________________________ MI___
DATE OF BIRTH______________________ MALE__________ FEMALE__________
STREET ADDRESS________________________________________________________________
CITY_______________________________ STATE OK ZIP_________________
PHONE NUMBER___________________________________
SINGLE MARRIED DIVORCED/SEPARATED WIDOWED WIDOWER
SPOUSE’S NAME________________________________________________________________
SPOUSE’S DATE OF BIRTH_________________________________
=
NAME OF EMERGENCY CONTACT (1) ________________________________________________
PHONE_______________________________________
NAME OF EMERGENCY CONTACT (2) ________________________________________________
PHONE_______________________________________
=
PRIMARY LANGUAGE ENGLISH TRIBAL SPANISH
DO YOU HAVE BASIC LITERACY SKILLS? YES NO
(THOSE NECESSARY TO PERFORM SIMPLE AND EVERYDAY LITERACY ACTIVITIES)
HOUSING HOUSE APARTMENT COMMUNITY HOUSING
OTHER EXPLAIN__________________________________
COMPOSITION LIVES WITH SPOUSE LIVES WITH FAMILY/FRIENDS
LIVES ALONE OTHER EXPLAIN_____________________
# OF GRANDCHILDREN IN HOUSEHOLD ________________
TOTAL # OF PERSONS IN HOUSEHOLD ________________
=
HEALTH HISTORY ASTHMA ALZHEIMER’S ARTHRITIS CANCER
DEMENTIA DIABETES CHRONIC PAIN HEART
CHOLESTEROL BLOOD PRESSURE
OTHER_____________________________________________________________________
MEDICATIONS TIMES A DAY
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
=
INCOME (VOLUNTARY) _____________________________________________________________
OWNS TRANSPORTATION RELIES ON FAMILY/FRIENDS
OTHER____________________________________________________________________
=
INTERESTS, NEEDS, AND/OR CONCERNS
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
REQUEST FOR CONGREGATE MEALS
DELIVERED MEALS
THANK YOU FOR YOUR INTEREST IN THE DELAWARE NATION ADMINISTRATION ON AGING
NUTRITION SERVICES PROGRAM.
OUR PROGRAM PROVIDES A NUTRITIOUS LUNCH TO ELIGIBLE PARTICIPANTS,
(NATIVE AMERICAN ELDERS AGE 60+ THAT RESIDE WITHIN OUR SERVICE AREA)
FOUR DAYS A WEEK (M-TR), WITH THE EXCEPTION OF HOLIDAYS, AND ANY OTHER DAY THE
DELAWARE NATION COMPLEX IS CLOSED.
I HAVE RECEIVED, READ, AND UNDERSTAND THE POLICY OF CONDUCT AND RULES OF CONDUCT,
AND HEREBY AGREE TO ABIDE BY THESE AT ALL TIMES.
I ALSO UNDERSTAND THAT IN THE EVENT IT IS DISCOVERED THAT I FALSIFIED ANY
DOCUMENTATION PERTAINING TO THIS APPLICATION, WHETHER VERBALLY OR WRITTEN, I
FORFIET ANY FURTHER SERVICES FROM THE DELAWARE NATION NUTRITION PROGRAM.
THE AOA DIRECTOR WILL REVIEW ALL COMPLETE SUBMISSIONS OF THE ATTACHED
APPLICATION, ALONG WITH A COPY OF YOUR CDIB CARD, A RECENT UTILITY BILL SHOWING
PROOF OF RESIDENCE, AND PROOF OF DISABILITY ( IF APPLICABLE).
YOU WILL THEN BE NOTIFIED OF APPROVAL/DENIAL WITHIN 10 DAYS.
=
APPLICANT
=
DIRECTOR DATE
-------------------------------------------------------------------------------------------------------------------------------
FOR OFFICE USE ONLY APPROVED_____________ DENIED_____________
REASON______________________________________________________________________________
REFERRED TO__________________________________________________________________________
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ELDER INTAKE FORM PLEASE PRINT CLEARLY (Delaware Nation)

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Completed 20 July 2020

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