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Aster Participant Registration Form

All information is kept strictly confidential.


Personal Information

Last Name
First Name
Middle Initial
Date of birth
Gender
Country
Address Line 1
City
State
Postal Code
Country
Address Line 1
City
State
Postal Code
Phone (cell)
Phone (home)
Chronic Health Conditions
Documented Disability

DEMOGRAPHICS

Marital Status
Ethnicity
Race
Monthly Income
Number in Household
Household Makeup
Have You Served In the Military?
Which Aster Senior Center do you plan to visit most frequently?
How Did You First Learn About The Center?

Nutritional Assessment

The warning signs of poor nutritional health are often overlooked. Read the statements below and select "yes" or "no" for each statement.

I have an illness or condition that made me change the kind and/or amount of food I eat.
I eat fewer than 2 meals per day.
I eat few fruits or vegetables or milk products.
I have 3 or more drinks of beer, liquor, or wine almost every day.
I have tooth or mouth problems that make it hard for me to eat.
I don't always have enough money to buy the food I need.
I eat alone most of the time.
I take 3 or more different prescribed or over-the-counter drugs a day.
Without wanting to, I have lost or gained 10 pounds in the last 6 months.
I am not always physically able to shop, cook, and/or feed myself.

Emergency Contacts

Please provide the name, phone number, and relationship of two individuals we can contact in the case of an emergency situation.

Name 1
Phone
Phone Number
ext Extension
Relationship
Name 2
Phone
Phone Number
ext Extension
Relationship

Photo Notice

Aster Aging, Inc. regularly records our Senior Center programs and services. This may take the form of photos, video or audio recordings, digital images, and the like. Aster uses these on social media, advertisements, flyers, newsletter and more to promote our services and educate the public, in accordance with our mission. By participating in our activities, you understand and grant permission to Aster Aging to use your name, likeness, image, voice, and/or appearance as a program participant. Furthermore, I acknowledge that I will not receive any compensation for the use of such pictures, etc., and hereby release Aster Aging from any and all claims which arise out of or are in any way connected with such use.


Electronic Communication Notice

Aster Aging, Inc. utilizes member email addresses to share important information, program activities, solicit feedback, and more. Communication can take the form, among others, of individual emails, group emails, and eNewsletters. While Aster will utilize your email address to communicate, we will never sell, share or trade your address to any outside organization. Your privacy is important to us!


Participant Signature

My typed name below attests to the fact that I have read, understand, and agree to all of the above terms.

Signature
Today's Date


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