Participant Registration Form

2. Senior Nutrition Registration Form

   The Senior Nutrition Program (SNP) provides on-site and home-delivered meals for older adults throughout Washtenaw County to maintain health, housing stability, and independence.  Seniors 60 and over have access to this program and meals are available at a suggested donation of $3 per meal.  No senior is ever turned away for lack of payment or donation.  Guests under 60 are required to pay $5.50 per meal.

4. Name
5. Email Address
7. Address
9. City
10. State
11. Zip Code
13. Phone Number
14. Fax Number
15. Date of Birth*
    Date of Birth
19. Demographic Information

    Please complete this section of information as it is very important to our program.  This information allows us access to funding based on the demographics of our participants.  Your information is only shared as data outside of our program.  All demographic information is used for grants, advocacy and fundraising. All information is shared data and aggregate information it is not shared in a way that it can be traced back to you as a individual.

21. I decline to provide answers to these demographic questions

    1. Yes
    2. No
23. # of people living in the household
25. Gender

    1. Male
    2. Female
    3. Transgender
    4. Prefer not to say
    5. Unknown
    6. Other
27. Client Sexual Orientation

    1. Straight/Heterosexual
    2. Lesbian
    3. Gay
    4. Bisexual
    5. Prefer not to say
    6. Unknown
    7. Other
29. Marital Status

    1. Married
    2. Divorced
    3. Widowed
    4. Single(never married)
31. Race

    1. White
    2. Black/African American
    3. American Indian/Alaskan Native
    4. Asian/Native Hawaiian/Pacific Islander
    5. Multi-racial:
    6. Other
33. Are you Hispanic/Latino

    1. Yes
    2. No
35. Current Living Arrangements

    1. Own Home
    2. Rent Subsidized Home (section 8)
    3. Rent unsubsidized Home
    4. In Transition/Shelter
    5. Living With Family/Friends
    6. Homeless
37. Yearly Household Income (estimated)

    1. Below $13,590 Annually ($1,133 monthly)
    2. $13,590 - $18,075 Annually ($1,134 -1,1506 monthly)
    3. $18,076 - $18,754 Annually ($1,507 - $1,563 monthly)
    4. $18,755 - $20,385 Annually ($1,564 - $1,699 monthly)
    5. $20,386 - $27,180 Annually ($1,700 - $2,265 monthly)
    6. $27,181 - $40,770 Annually ($2,266 - $3,398 monthly)
    7. $40,771 -$54,360 Annually ($3,399 - $4,530 monthly)
    8. $54,360 + Annually (more than $4,531 monthly)
39. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
41. Electronic Signature
45. Senior Cafe

    Meals are available to guest 60 years of age or older for a suggested $3 per meal.  No guest will be turned away for inability to pay for a meal.

    Guests under 60 years of age can purchase a meal for $5.50 per meal.

    
    

47. Senior Cafe Sites

    If you are going to be attending Senior Cafe Programs, please check all sites you plan to attend.

    1. Chelsea Senior Center 512 E Washington Chelsea, MI 48118 Phone: 734-475-9242
    2. Dexter Senior Center 7720 Ann Arbor Street Dexter, MI 48130 Phone: 734-426-7737
    3. Jewish Community Center 2935 Birch Hollow Ann Arbor, MI 48107 Phone: 734-971-0990
    4. Milan Seniors for Healthy Living 45 Neckel Court Milan, MI 48160 Phone: 734-508-6229
    5. Northfield Township Community Center 9101 N Main Street Whitmore Lake, MI 48189 Phone: 734-449-2295
    6. Pittsfield Senior Center 701 W Ellsworth Ann Arbor, MI 48107 Phone: 734-822-2117
    7. Turner Senior Wellness Program 2401 Plymouth Road Ann Arbor, MI 48107 Phone: 734-998-9350
    8. Ypsilanti Senior Center 1015 Congress St., Ypsilanti, MI 48197 Phone: 734-483-5014
    9. Ypsilanti Township Community Center 2025 E Clark Ypsilanti, MI 48198 Phone: 734-544-3838
51. MEALS ON WHEELS/HOME DELIVERED MEALS

    Meals on Wheels/Home Delivered Meals are available to guest 60 years of age or older that qualify for home delivered meals.  Meals are available for a suggested $3 per meal.  No guest will be turned away for inability to pay for a meal.

    Guests under 60 years of age can purchase a meal for $5.50 per meal.

    Please Complete this section if you are interested in receiving HOME DELIVERED Meals.  To qualify for home delivered meals, you must be medically homebound and you must not be about to prepare meals for yourself or have someone who is able and willing to prepare daily meals for you.

    **Please note that additional paperwork may be required by the Home Delivered Meal Program that is responsible for providing your meals.  You meal provider will contact you before any meals will be delivered.

53. Meals on Wheels/Home Delivered Meal Providers
    https://www.washtenaw.org//snp

    Using the link above determine your Meals on Wheels/Home Delivered Meal Provider.

55. What types of meals are you interested in receiving?

    Please check all that apply.

    1. Hot Meals

    1. 2nd Meals (Cold Meals)

    1. Frozen Meals
57. What days of the week do you need meals for?

    Please check all days that you wish to receive meals for.

    1. Sunday
    2. Monday

    1. Tuesday
    2. Wednesday

    1. Thursday
    2. Friday

    1. Saturday
59. Meals on Wheels/Home Delivered Meal Programs

    Using the link above determine which program provides services in your area and check the appropriate checkbox.

    1. Ann Arbor Meals on Wheels Phone: 734-998-6686
    2. Chelsea / Manchester Meals on Wheels Phone: 734-475-9245
    3. Dexter Senior Center 7720 Ann Arbor Street Dexter, MI 48130 734-426-7737
    4. Milan Seniors for Healthy Living 45 Neckel Court Milan, MI 48160 734-508-6229
    5. Northfield Township Community Center 9101 N Main Street Whitmore Lake, MI 48189 734-449-2295
    6. Ypsilanti Meals on Wheels Phone: 734-487-9669

63. REFERRAL INFORMATION

    Please complete this section if you are referring a client to the Washtenaw County Meals on Wheels Program.

65. First Name
66. Last Name
68. Agency Name
69. Phone Number
71. Email Address
73. Comments/Information
Leave This Blank:


75. 1. Receive an email copy of this form.
76. Email address

    This field is not part of the form submission.

77. Submit

* indicates a required field