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Menu
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Independent Living
Apartments
Villas
Virtual Tours
Assisted Living
Breese Apartments
Memory Care
Breese Virtual Tours
Healthcare Services
Skilled Nursing
Rehabilitation Services
Hospice Care
Virtual Tours
Lifestyle
Life Enrichment
Amenities
Health and Wellness
Services
Community
Community Partnerships
Community News
Volunteer Opportunities
Maple Knoll Arboretum
Upcoming Events
Outreach Services
Senior Housing
Resources
Pricing
Levels of Care
Join Club MKV
Maple Knoll Blog
COVID Update
About Us
Careers
MKC Foundation
Contribute
Leadership
Annual Reporting
A BHI Affiliate
Contact Us
Schedule a Visit
Living Accommodations
Independent Living
Apartments
Villas
Virtual Tours
Assisted Living
Breese Apartments
Memory Care
Breese Virtual Tours
Healthcare Services
Skilled Nursing
Rehabilitation Services
Hospice Care
Virtual Tours
Lifestyle
Life Enrichment
Amenities
Health and Wellness
Services
Community
Community Partnerships
Community News
Volunteer Opportunities
Maple Knoll Arboretum
Upcoming Events
Outreach Services
Senior Housing
Resources
Pricing
Levels of Care
Join Club MKV
Maple Knoll Blog
COVID Update
About Us
Careers
MKC Foundation
Contribute
Leadership
Annual Reporting
A BHI Affiliate
Contact Us
Schedule a Visit
Menu
Living Accommodations
Independent Living
Apartments
Villas
Virtual Tours
Assisted Living
Breese Apartments
Memory Care
Breese Virtual Tours
Healthcare Services
Skilled Nursing
Rehabilitation Services
Hospice Care
Virtual Tours
Lifestyle
Life Enrichment
Amenities
Health and Wellness
Services
Community
Community Partnerships
Community News
Volunteer Opportunities
Maple Knoll Arboretum
Upcoming Events
Outreach Services
Senior Housing
Resources
Pricing
Levels of Care
Join Club MKV
Maple Knoll Blog
COVID Update
About Us
Careers
MKC Foundation
Contribute
Leadership
Annual Reporting
A BHI Affiliate
Contact Us
Schedule a Visit
Outreach Services for Seniors
Information Sheet
"
*
" indicates required fields
Step
1
of
4
25%
Please check all services that apply to you:
*
Transportation
Home delivered meals
Home health
How did you hear about us?
*
Friends/Neighbors
Newspaper
Website
State agency
Cable TV
Other
Full Name
*
First
Last
Birthdate
*
MM slash DD slash YYYY
Home Phone Number
*
Cell Phone Number
*
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Community (Ex: Blue Ash)
*
Any "Also Known As" Name(s)
*
In Case of Emergency Contacts
Contact 1
Full Name
*
First
Last
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Home Phone Number
*
Work/Cell Phone Number
*
Relationship
*
Contact 2
Full Name
*
First
Last
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Home Phone Number
*
Work/Cell Phone Number
*
Relationship
*
Demographic Information
Gender
*
Female
Male
Race
*
Asian
Black/African American
Hispanic
White
Other
Currently resides in:
*
Home/mobile home
Private apartment
Nursing home
Private apt in senior housing
Residential care home
Unavailable
Other
How long in this residence?
*
Less than 12 mos.
1-3 years
3 years or more
Marital status
*
Divorced
Married
Separated
Never
Married/Single
Widowed
Living Arrangement
*
Living Alone
With Spouse/Partner
Other
Are you employed?
*
Yes
No
Refused
Primary Care Physician
*
Hospital Preference
*
Medical Information
Please list any important medical information, such as allergies or diabetes that we need to be aware of in case of an emergency.
Disclosure Statement
The Client Registration Form was developed to assist the Council on Aging to monitor the effectiveness of senior programs offered to the citizens of Ohio. Any client information obtained from this form will be kept confidential and no personal identifying information about a client (i.e. name, address, telephone number, etc…) will be released to the public without the client’s prior written consent, or unless otherwise required under federal law. The data collected (i.e. age, sex, race, etc.) will be forwarded to the Council on Aging and summarized and reported to the Ohio Department of Aging (ODA) and the Administration on Aging (AOA) in order to keep both state and federal legislators informed on the effectiveness of senior programs (as required by the Older Americans Act reauthorization). While all clients receiving services under the Older Americans Act are asked to complete the attached form in full, no client may be denied services for refusing to provide any of the information requested, including Social Security number. If you have any questions, ask a staff member to explain why this is necessary.
Privacy Notice
The above health information will only be used or disclosed to provide you with treatment and services in the case of illness or injury that occurs while on a trip.
Authorization/Release
I agree to release from liability, MKOSS staff and volunteers for any injury or illness accidentally incurred by me. First aid may be administered by a competent person. In the event of an emergency, I hereby give permission to the person in charge to send me to a physician or hospital, as required.
Consent for Release of Information
I authorize the MKOSS to share information obtained in the assessment process and updates with other professional agencies for the purpose of planning services to meet my needs, including both personal and medical files. I also understand that I can revoke this consent at any time by calling Social Services at 984-1234. My signature further indicates that I have read or had read and explained to me this consent and the information to be released.
Consent
*
I accept the terms and conditions and have read/understand the disclosure statement provided to me.
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