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
MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number*
Please enter a valid phone number.
Cell Phone Number*
Please enter a valid phone number.
Pick One*

SingleMarriedDivorced/SeparatedWidowed/Widower
Veteran*

NoYes - 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.
Name of Emergency Contact (2)

First NameLast Name
Emergency Contact (2) Phone Number
Please enter a valid phone number.
Primary Language*

TribalEnglishSpanishOther
Tribal Information

TribeClan
Preferred Communication*

WrittenOral
Does the Elder have basic literacy skills (those necessary to perform simple and everyday literacy activities)?*

YesNo
Type of Housing*

HouseApartmentCommunity HousingOther
Housing Composition*

Lives AloneLives with SpouseLives with Family/FriendsOther
Total Number of Persons in Household*
Total Number of Grandchildren in Household*
Health History

AsthmaAlzheimer'sArthritisCancerDiabetesDementiaChronic PainFallsHigh CholesterolBlood PressureHypertensionOther
Elder takes the following medication (Please list all medications and the number of times a day taken)
Elder uses Prosthetic Devices*

Walker/CaneWheelchairHearing AidGlassesDenturesNone
Primary Transportation*

OwnRelies on Family/FriendsTribalOther
Income (voluntary)
Elder has experienced an increase in

Health IssuesFinancial IssuesFeelings of IsolationHousing IssuesScamsEmployment IssuesOther
Elder's interests, needs and/or concerns
Request (Check One)*

Congregate/On-site MealsDelivered MealsNone at this time
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

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