Senior Confidential Information Form

Senior's Information

Senior's Full Name

Gender

Female Male Decline to State

Are you a Veteran?

Yes No

Residence Address

Apartment #

City

Zip Code

Mailing Address

Apartment #

City

Zip Code

Cell Phone

Home Phone

Birthdate

Age

Are you disabled?

Yes No

Do you live alone?

Yes No

Emergency Information

Emergency Contact Name

Relationship to Senior

Phone

Alternate Phone

Agreements

Facility Purpose

By checking this box, I understand that the Clovis Senior Center is an independent participation facility and not an adult day care facility or an assisted living facility.

Photography permission

By checking this box, I consent to be photographed by a representative of the Clovis Senior Activity Center for the purposes of Senior Activity Center publications. (i.e. website, newsletter called NEWSWAGON), and program events.

Code of Conduct

By checking this box, I verify that I have reviewed and agree to abide by the Clovis Senior Center Code of Conduct policy.

Senior Services • (559) 324-2750
8 AM – 5 PM • Mon – Fri