Form DAAS101

Client Registration Form

Client Registration Form

Legal Name(Required)
Address(Required)
MM slash DD slash YYYY
Max. file size: 256 MB.
Max. file size: 256 MB.
If you are unable to upload your driver's license and receipts. Please mail a copy to P.O. Box 1717, New Bern, NC 28560.
Sex(Required)
At or Below Poverty Level?(Required)
Marital Status(Required)
Household Size(Required)
Ethnicity(Required)
(Are you of hispanic or latino origin?)
Client's Overall Functional Status(Required)
Enter the client's self-reported overall functional status here.
Nutrition Health Score
Do you have an illness or condition that made you change the kind and/or amount of food you eat?(Required)
Do you have tooth/mouth problems that make it hard for you to eat?(Required)
Do you have enough money or food stamps to buy the food you need?(Required)
Have you lost 10 or more pounds in the past 6 months without trying?(Required)
Have you gained 10 or more pounds in the past 6 months without trying?(Required)
Are you physically able to shop for yourself?(Required)
Are you physically able to cook for yourself?(Required)
Are you physically able to feed yourself?(Required)
Required For All Clients I, the client, understand that the information contained on this form will be kept confidential unless disclosure is required by court order or for authorized federal, state, or local program reporting and monitoring. I understand that any entitlement I may have to Social Security benefits or ther federal state sponsored benefits shall not be affected by the provision of the aforemention information. My signature authorizes the providing agency to begin the service(s) requested.
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