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Senior Confidential Information Form

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Activities and Info
Business/Non-Senior Information Form
Senior Safety
Senior Confidential Information Form

Senior's Information

Senior's Full Name

Gender

Female Male

Veteran

Yes No

Street Address

Apartment #

City

State

Zip Code

Phone

Email

Birthdate

Age

Health Information (Optional, but helpful in emergency medical situations)

Doctor or Clinic Name

Doctor/Clinic Phone

Are you disabled?

Yes No

Medications

Health and/or Nutrition problems

Medical Coverage

Do you live alone?

Yes No

Race/Ethnicity

White Hispanic Black Asian American Indian Other Decline to Answer

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.

Monthly Newsletter Options

I would like the monthly newsletter mailed to my home address I would like the monthly newsletter emailed to my email address above I would like to pick up the monthly newsletter at the Senior Activity Center I do not want the newsletter at this time

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

City of Clovis • 1033 Fifth Street • Clovis, CA • 93612 • TTY 711

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