Home

Membership Form

Thank you for your interest in the City of San Antonio’s Senior Services Program. Whether you are interested in joining us for a midday meal, group exercise, a computer class or to meet up with a friend, we welcome you! To enroll, please complete the form below and allow 2-3 business days for your application to be processed.

Highlighted fields containing an asterisk * are required.

Date Registered
10/04/2024

Location *

Member Information
Eligibility
Volunteer
Nutrition
Other
Agreement

Member Information Step 1 of 6

Do you want to participate in the Meal Program?*

Create a Login ID*

Create a Password* (Must be 8 to 10 characters)

First Name *

Middle Initial

Last Name *

Suffix

Gender *

Date of Birth *(mm/dd/yyyy)

Marital Status *

Last four of SSN

Ethnicity *

Race *

Street Address *

Apartment

Zip Code *

County*

City*

State*

Council District

Participant's Phone # *

Physician Name

Physician Phone #

Emergency Contact Name *

Emergency Contact Relationship *

Emergency Contact Phone # *

Please review the following required field(s):

Eligibility Step 2 of 6

Are you 60 years of age or older?
Yes No

Are you a spouse of an eligible and registered participant?
Yes No

Please provide the name of your spouse. *

Are you disabled and residing in a senior housing complex?
Yes No

If residing in a senior housing complex, which complex? *

If less than 60 years of age, are you disabled, residing with, and accompanying an eligible participant who is 60 years of age or older?

Yes No

Please provide the name of the eligible participant with whom you reside with and are accompanying to the center. *

If you are less than 60 years of age, are you a Volunteer for the meal program?
Yes No

How many people reside in your household? *

Do you live alone? *

Yes No

What is your income level?* :

Low
Middle
High

Are you employed?
Yes No

Do you receive Medicaid? *

Yes No

Do you receive Medicare? *

Yes No

Do you receive Supplemental Security Income (SSI), Social Security Disability Income (SSDI), or Social Security Retirement (SS)? *

Yes No

Ethnicity *

Hispanic or Latino
Not Hispanic or Latino

Number of ADLs

Number of IADLs

Please review the following required field(s):

Volunteer Step 3 of 6

Are you or would you like to be a volunteer? *

Yes No

Where do you want to be a volunteer? *

Volunteer area of Interest *

Please review the following required field(s):

Nutrition Step 4 of 6

Please complete the Nutritional Risk Assessment below. If your response to the statement is "Yes," select the box that corresponds to that statement.

I have an illness or condition that made me change the kind and/or amount of food I eat *

Yes No

I eat fewer than 2 meals per day *

Yes No

I eat few fruits or vegetables, or milk products *

Yes No

I have 3 or more drinks of beer, liquor or wine almost every day *

Yes No

I have tooth or mouth problems that make it hard for me to eat *

Yes No

I don't always have enough money to buy the food I need *

Yes No

I eat alone most of the time *

Yes No

I take 3 or more different prescribed or over-the-counter drugs a day *

Yes No

Without wanting to, I have lost or gained 10 pounds in the last 6 months *

Yes No

I am not always physically able to shop,cook and/or feed myself *

Yes No

Please review the following required field(s):

Other Step 5 of 6

Is a Veteran:

Yes No

Is veteran dependent :

Yes No

Is a high nutrition risk:

Yes No

Lives in a rural area:

Yes No

Are you living in poverty? *

Yes No

Days of the week needed to be picked up from home:

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Days of the week needed to be drop off from home:

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Please review the following required field(s):

Is a high nutrition risk:

Yes No

Lives in a rural area:

Yes No

Are you living in poverty? *

Yes No

Is receiving Social Security:

Yes No

Is eligible for medicare:

Yes No

Please review the following required field(s):

Agreement Step 6 of 6

To complete your enrollment at a City operated senior center and/or a Nutrition Program partner site, please view and select "yes" to confirm that you have received information regarding member eligibility, senior center policy and rules of conduct, senior services grievance and complaint procedures, client rights and responsibilities and release of information; and that you agree to the terms of the policies listed.

Member Eligibility, Center Policy, and Rules of Conduct * Yes No View

Grievance and Complaint Procedures * Yes No View

AAA Client Rights, Responsibility, Release of Information, and Veteran Resource * Yes No View

Data Privacy Policy and Client Release of Information * Yes No View

Disclaimer: My electronic signature below attests that I am the person represented in this application, that the information contained herein is true and accurate to the best of my knowledge, and serves as my consent to apply for services through AACOG and the City of San Antonio. I understand that my information may be shared to effectively plan, arrange, and deliver services to meet individual client needs. I have read, understand and agree to the terms of the Attachments herein.

Acceptance of all terms and policies: I understand that my information may be shared to effectively plan, arrange, and deliver services to meet individual client needs. I have read, understand, and agree to the terms of the attachments herein.*

Type your full (Legal) name here. * :

Signature

Please review the following required field(s):

Program founded by

Powered by

Office of Equity |
ADA Compliance |
Open Records |
Contact Us |
Privacy & Disclaimer