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Serving Seniors Meal Application

All people over 60 year old can receive Serving Seniors meal program, this application is basic information that they require to have before starting lunch services for individuals.

You may complete this application online or in person at the center.

This application is for PICK UP ONLY. Please come to the center to complete a delivery application.

First name*

Last name*

Birthday*

Month

Day

Year

Phone*

Multi-line address

Country/Region*

Address*

City*

Zip / Postal code*

Living Arrangement: # of household members*

What is your approximate household income per year?

Rural Area?*

Yes

No

Declined

What is your gender?*

What was your sex at birth? *

Male

Female

Declined

How do you describe your sexual orientation or sexual identity? *

Straight/Heterosexual

Bisexual

Gay/Lesbian

Unsure

Other

Have you ever served in the US military?*

Yes

No

Declined

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

Yes

No

Declined

If Yes, check below if "I consent to this agency and the CA Department of Aging transmitting my name, email address, mailing address, and mobile telephone number to CalVet only for the purpose of receiving additional information on veteran benefits"

Yes

No

Ethnicity *

Hispanic

Not Hispanic

Language

English

Need interpreter

Non English

Race*

Nutritional Risk Assessment *Choose if YES* *

I have an illness or condition that made me change the kind of food and/or amount of food I eat. (2)

I eat fewer than 2 meals per day. (3)

I eat few fruits or vegetables or milk products. (2)

I have 3 or more drinks of alcohol every day. (2)

I have tooth or mouth problems that are it hard for me to eat. (2)

I don't always have enough money to buy the food I need. (4)

I eat alone most of the time. (1)

I take 3 or more different prescribed or over the counter drugs a day. (1)

Without wanting to, I have lost or gained 10 pounds in the past 6 months. (2)

I am not always physically able to shop, cook, or feed myself. (2)

Declined

Total score of assessment*

0-5

6+

Signature*

Sign in the box or use the keyboard to type.

Signature field is empty.

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HOURS OF OPERATION

Classes held throughout the week— see monthly calendar for details

Reception Desk open Monday through Thursday from 9:00 a.m. to 3:00 p.m.; Friday 9:00 a.m. to 1:00 p.m.

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