Professional Documents
Culture Documents
Address ______________________________________County________________
Married_____ Widowed___
City ______________________________State: ___________Zip: ______________ Single _____ Divorced ___
Race_______ Sex_________
Phone ___________________ __________________ _____________________ Number in household________
(Home) (Work) (Cell phone)
Check all that apply:
E-Mail Address (please print)____________________________________________ *required by federal/state funding agencies
____I live alone.
Is Spouse a member ___ If yes, please give his/her full name _________________
____I have 2 or more health conditions
Social Security # last 4 digits please:____________ Birth Date _____/_____/_____ monitored by a physician.
____I am eligible to receive public
In Case of Emergency, notify ______________________ Relationship___________ assistance.
____I have limited English language
Emergency _________________ ___________________ ___________________ skills.
(Day phone) (Evening phone) (Cell phone) ____I am unable to drive.
____I have a disability,
Your physician________________________ Physician Phone ________________ (describe)______________________.
Information required by federal/state funding agencies:
_____ GRIEVANCE PROCEDURE
Is your income at/below $850.83/ Single per month ___ yes ___ no By my initials, I understand that if I have a
$1,140.83/ Couple per month ___ yes ___ no serious complaint about not receiving
Is your income at/below $1,701.67/ Single per month ___ yes ___ no adequate service from FiftyForward, I have
the right to complain to the proper
$2,280.00/ Couple per month ___ yes ___ no authorities with no penalty to me. A copy of
the Grievance Policy will be made
available upon request.
Signature _________________________________Date _______________
RELEASE OF INFORMATION FOR STATISTICAL REPORTING
I understand that the information collected will not be identified with me personally. It may be used in statistical reports. I give my
permission to use the information for statistical reporting.