Client Application
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Name of person completing this form: *
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Relationship to Applicant: *
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Contact Phone Number: *
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Contact Email: *
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A copy of the information submitted in this form will be sent to this email.
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Who should we contact for further questions? *
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Applicant Information
Please provide the following information for the potential client.
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Applicant Name: *
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Age: *
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If under 65, we will require a letter from his/her doctor stating the medical conditions that confine the applicant to his/her home and/or render them unable to
prepare meals.
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Date of Birth: *
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(MM/DD/YYYY)
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Address: *
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Please enter Street Address, City, State, and Zip Code.
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Phone Number: *
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Primary Language: *
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Home Health Provider:
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If none, leave blank.
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Home Health Phone Number (if applicable):
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Which days are home health in home?
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Monday
Tuesday
Wednesday
Thursday
Friday
Please check all that apply.
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What hours are home health in home?
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Please list beginning time to end time for each day.
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Total number of people living in the household (including the applicant): *
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Doctor's Name:
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Doctor's Phone Number:
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Health Problems: *
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Condition Type:
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Permanent
Temporary
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Length of Condition (if temporary):
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Diet Type: *
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Regular
Diabetic
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Name of Next of Kin:
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Relationship to Applicant:
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Address:
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Please enter Street Address, City, State, and Zip Code.
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Home Phone Number:
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Work Phone Number:
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Cell Phone Number:
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Emergency Contact Information
If a client is not home or is unable to answer the door, please provide contact information for at least two people our office could call to check on them. Must
be different from next of kin. Can be a neighbor, relative, or friend.
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Emergency Contact #2: *
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Relationship to Applicant:
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Home Phone Number: *
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Work/Cell Phone Number:
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Emergency Contact #3:
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Relationship to Applicant:
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Home Phone Number
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Work/Cell Phone Number
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Additional Information
A description of the section goes here.
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Will someone be contributing for the applicant's meals? *
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Yes
No
Inability to contribute for meals will not deter applicant eligibility; however, our program relies solely on donations, and all contributions are
welcomed.
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Who will be contributing?
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Please enter the name and relationship to applicant, or enter "self" if applicant will be contributing. Leave blank if unable to contribute.
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Would you like to receive supplemental pet food?
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Yes
No
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Number of dogs:
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Number of cats:
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Is the applicant a veteran?
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Yes
No
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If so, which branch of service?
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Did applicant serve during a conflict? If so, list service date of conflict:
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Please describe the outside appearance of the applicant's home and/or directions for locating the home. *
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(For example: white house with brown trim, corner of 8th & Chadbourne.)
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Spouse Information
Please note you must submit a separate application if applying for a spouse as well.
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If you will also be submitting an application for a spouse, please enter the spouse's name here.
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Image Verification
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