Elder Intake Form

Elder Intake Form

Meskwaki Senior Services
Thank you for your interest in Meskwaki Senior Services. Our program provides a nutritious lunch to *eligible participants, five days a week (Monday-Friday), with the exception of holidays.

*Eligability: Native American elders (age 55 and above) that reside within our service area.
Name of Elder (Applicant)

First NameMiddle NameLast NameSuffix
Indian Name
Email
example@example.com
Date of Birth

DayMonthYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Pick One
Veteran

Yes - If yes, please list Branch
Spouse's Name (if applicable)

First NameLast Name
Spouse's Date of Birth

DayMonthYear
Date
Name of Emergency Contact (1)

First NameLast Name
Emergency Contact (1) Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Name of Emergency Contact (2)

First NameLast Name
Emergency Contact (2) Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Primary Language

Other
Tribal Information

TribeClan
Preferred Communication
Does the Elder have basic literacy skills (those necessary to perform simple and everyday literacy activities)?
Type of Housing

Other
Housing Composition

Other
Total Number of Persons in Household
Total Number of Grandchildren in Household
Health History

Other
Elder takes the following medication (Please list all medications and the number of times a day taken)
Elder uses Prosthetic Devices
Primary Transportation

Other
Income (voluntary)
Elder has experienced an increase in

Other
Elder's interests, needs and/or concerns
Request (Check One)
List name of person filling out this form (if other than elder/applicant listed on the top of this form)

First NameLast Name
Please understand that by signing below, you agree that the information in this application is accurate and true. If it is discovered that information has been falsified, the elder will forfeit services from the program.

The Senior Services Director will review all completed submissions and contact will be made with the applicant regarding approval.
Signature

Clear
Should be Empty: