The Native Village of Eyak
Elder Services Program In-Take Form
Today’ Date:____________________
Date of Birth:___________________
Elder Contact information (please print)
First Name:_____________________________________________________________
Last Name:_____________________________________________________________
Street Address:__________________________________________________________
Post office box:__________________________________________________________
Home phone #___________________Cell phone#______________________________
Email address:___________________________________________________________
On File with enrollment: Birth Certificate: □ CIB: □
Alaska Native: □ American Indian: □ Non-Enrolled Alaska Native: □
Regional Corporation:___________________________________________________________
Village Corporation:_____________________________________________________________
How would you like to be contacted? Mark all that applies
Robo call □ regular phone call □ email □ text □ mail □
Directions of Home/Color of house/ Identifying landmarks
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Do you have: Medicaid □ or Medicare □
