Fillable LUNCH CAF PROGRAM CLIENT REGISTRATION FORM (City of Yorba Linda)

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LUNCH CAF PROGRAM CLIENT REGISTRATION FORM (City of Yorba Linda)

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File type: PDF

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LUNCH CAFÉ PROGRAM
CLIENT REGISTRATION FORM
PLEASE “PRINT” ALL INFORMATION ON THIS FORM
This information is being collected for total program purposes and does not
have any bearing on your participation. All information will remain confidential.
This program is funded in part by the U.S. Department of Housing and Urban Development (HUD).
Site Name: Yorba Linda
Registration Date:
Client ID #:
First Name:
Last Name:
*Birth Date:
Home Phone #:
Title III B Eligibility:
Are you age 60 or over?
Yes No
Veteran:
Yes No
Branch:
Residential Address:
Street:
City:
*Zip Code:
*Rural?
Rural Urban
Decline to State
*Living
Arrangement
Lives Alone
Doesn’t Live Alone
Decline to State
Female Head of Household
Yes No
A female who maintains a household for themselves, a
dependent or non-depended relative, and provides more
than half of the dependent’s financial support.
Disable
Yes No
A physical, mental or emotional condition lasting longer
than 6 months or more that makes it difficult to perform
basic physical activities; such as walking, climbing
stairs, reaching, lifting or carrying.
*Gender/Identity
Male Female
Transgender Female to Male
Transgender Male to Female
Genderqueer/Gender Non-binary
Other:
_____________________
Declined to State
Sex at Birth
Male Female
Declined to State
Sexual Orientation
Straight/Heterosexual
Bisexual
Gay/Lesbian/Same-Gender Loving
Questioning/Unsure
Other:
_____________________
Declined to State
*Ethnicity:
Not Hispanic/Latino
Hispanic/Latino
Declined to State
*Race: (Please Check ONE)
White Black/ African American
American Indian/Alaska Native
Other Race
Multiple Race (check all that apply)
Asian:
Chinese Korean Laotian
Japanese Vietnamese Cambodian
Filipino Asian Indian Other Asian
Hawaiian/Other Pacific Islander:
Guamanian Hawaiian Samoan
Other Pacific Islander
Declined to State
Hispanic: (CDBG)
Mexican Cuban
Puerto Rican Other Hispanic/Latino
TURN OVER
SITE ONLY
62 & Over (CDBG)
Verified: Yes No
By: _______________
Print Staff Name
Eligible Volunteer
Eligible Spouse
Eligible Disabled
**SITE MANAGERS: If the participant “declines to state” any information on this form, the site manager must “DTS and initial those fields.
*Bold & italic items are for CARS informational purposes.
Rev. 4/20
*Federal Poverty Level (FPL)
At or below Federal Poverty Level = Level 1 below
Above Federal Poverty Level = Level 2-5 below
Declined to State
Monthly
Income
Levels
Check
ONE
# Persons in Household: ________
1 Person
2 People
3 People
4 People
*FPL
1
$0 - $1,063
$0 - $1,437
$0 - $1,810
$0 - $2,183
30%
2
$1,064 - $2,246
$1,438 - $2,567
$1,811 - $2,888
$2,184 - $3,204
50%
3
$2,247 - $3,738
$2,568 - $4,271
$2,889 - $4,804
$3,205 - $5,338
80%
4
$3,739 – $5,979
$4,272 - $6,833
$4,805 - $7,688
$5,339 - $8,538
Over 80%
5
$5,980 and above
$6,834 and above
$7,689 and above
$8,539 and above
Declined to State
Income Levels eff.4/1/20
*Nutritional Assessment: (Circle an answer for each question)
No
Yes
Declined to State:
I have an illness or condition that made me change the kind and/or amount of food I eat?
0
2
I eat fewer than 2 meals per day?
0
3
I eat few fruits or vegetables, or milk products?
0
2
I have 3 or more drinks of beer, liquor, or wine almost every day?
0
2
I have tooth or mouth problems that make it hard for me to eat?
0
2
I do not always have enough money to buy the food I need?
0
4
I eat alone most of the time?
0
1
I take 3 or more different prescribed or over-the-counter drugs per day?
0
1
Without wanting to, I have lost or gained 10 pounds in the past 6 months?
0
2
I am not always physically able to shop, cook, and/or feed myself?
0
2
Total Score Today:
(If equal to or greater than 6, the client is at high nutritional risk.)
Emergency
Contact:
Name:
Relationship:
Phone:
( )
I certify this information provided is true to the best of my knowledge. If necessary, I will provide the information
required to verify this information given.
Client Signature
Date
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LUNCH CAF PROGRAM CLIENT REGISTRATION FORM (City of Yorba Linda)

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Completed 5 August 2020

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