Services Requested *

Transportation

Homemaking

Attendant Care

Respite Care

Medical Savings Plan

Medicare Counseling

Activity Center

Resource Library / Referrals

Other

Name *

First Name

Last Name

Street Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Type of Residence

Single Dwelling

Apartment Complex

Mobile Home

Duplex

Independent Living

Assisted Living

Skilled Nursing Facility

Township *

Baugo

Benton

Cleveland

Clinton

Concord

Elkhart

Harrison

Jackson

Jefferson

Locke

Middlebury

Olive

Osolo

Union

Washington

York

Home Phone *

(###)

###

####

Cell Phone *

(###)

###

####

Sex *

Male

Female

DOB *

MM

DD

YYYY

Race/Ethnicity *

Black / African American

Asian

American Indian

Alaskan

Hawaiian / Pacific Islander

Caucasian

Other

Hispanic *

Yes

No

Marital Status *

Single

Married

Divorced

Widowed

Name of Contact (individual not living with you) *

First Name

Last Name

Home Phone *

(###)

###

####

Cell Phone

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Responsible Party

First Name

Last Name

Individuals Living in Home *

Self

Spouse

Children

Other

Head of Household *

First Name

Last Name

Applicants relationship to head of household *

Self

Spouse

Child

Other

Do you live in HUD Housing *

Yes

No

Sources of Income *

Wages

Social Security

Disability

Pension

Other

Are you a veteran?

Yes

No

Mobility Status *

Unassisted

Assistance while walking

Cane

Walker

Wheelchair

Wheelchair Specifications

Extensions

Reclining

Folding

Motorized

Scooter

Can you self-transfer to a vehicle?

Yes

No

Do you require oxygen during transport? *

Yes

No

Phone of Primary Care

(###)

###

####

Date

MM

DD

YYYY