City Of Oakland Senior Companion Program Client Application Form Page 2
ADVERTISEMENT
1
2Medical Condition: (Please check all that apply)
Medical Condition: (Please check all that apply)
Medical Condition: (Please check all that apply)
Medical Condition: (Please check all that apply)
Alzheimer’s
Cancer
Cognitive/Learning Disability
Developmental
Diabetes
Hard of Hearing/Deaf
Heart/Stroke/Cardiovascular
Low Vision/Blind
Memory Lapse
Mobility/Physical
Psychological/Mental
Recent Surgery
Respiratory
Spinal Cord Injury
Other condition(s) not listed abo
Other condition(s) not listed abo
Other condition(s) not listed abo
Other condition(s) not listed above
ve ve
ve:
What medications do you take?
What medications do you take?
What medications do you take?
What medications do you take?
How did you hear about the Senior Companion or Taxi Up & Go Program
How did you hear about the Senior Companion or Taxi Up & Go Program? ? ? ?
How did you hear about the Senior Companion or Taxi Up & Go Program
How did you hear about the Senior Companion or Taxi Up & Go Program
Sr. Companion/Volunteer
Sr. Companion/Volunteer
Sr. Companion/Volunteer
Sr. Companion/Volunteer
Community Center
Community Center
Community Center
Community Center
Advertisement/Flyer
Advertisement/Flyer
Advertisement/Flyer
Advertisement/Flyer
Family/Friends
Family/Friends
Family/Friends
Family/Friends
Other
Other
Other
Other
If you were referred by an agency, please provide us with their information:
If you were referred by an agency, please provide us with their information:
If you were referred by an agency, please provide us with their information:
If you were referred by an agency, please provide us with their information:
Name/Title of person
Name/Title of person
Name/Title of person
Name/Title of person
Name of Agency/Organization
Name of Agency/Organization
Name of Agency/Organization
Name of Agency/Organization
Telephone Number
Telephone Number
Telephone Number
Telephone Number
Are you currently receiving taxi scrip from any other program
Are you currently receiving taxi scrip from any other program? (Please check all that apply)
? (Please check all that apply)
Are you currently receiving taxi scrip from any other program
Are you currently receiving taxi scrip from any other program
? (Please check all that apply)
? (Please check all that apply)
Taxi Scrip from Oakland Para-transit
Taxi Scrip from MSSP Case Management
Would you like additional info on other City of Oakland Senior Programs? (Please check all that apply)
Would you like additional info on other City of Oakland Senior Programs? (Please check all that apply)
Would you like additional info on other City of Oakland Senior Programs? (Please check all that apply)
Would you like additional info on other City of Oakland Senior Programs? (Please check all that apply)
OPED/Oakland Paratransit for the Elderly & Disabled
______MSSP/Case Management
ASSETS/Senior Employment Opportunities Program
Senior Centers
_____ Foster Grandparent Program
The information provided is correct and represents my current condition.
The information provided is correct and represents my current condition.
The information provided is correct and represents my current condition.
The information provided is correct and represents my current condition.
Client's Signature
Client's Signature
Client's Signature
Client's Signature
Date
Date
Date
Date
Please return this form by mail:
Please return this form by mail:
Or by FAX:
Or by FAX:
Please return this form by mail:
Please return this form by mail:
Or by FAX:
Or by FAX:
City of Oakland, De
City of Oakland, Department of Human Services
partment of Human Services
(510) 238
(510) 238- - - - 2378
2378
City of Oakland, De
City of Oakland, De
partment of Human Services
partment of Human Services
(510) 238
(510) 238
2378
2378
150 Frank H. Ogawa Plaza, Suite 4340, Oakland, CA 94612
150 Frank H. Ogawa Plaza, Suite 4340, Oakland, CA 94612
150 Frank H. Ogawa Plaza, Suite 4340, Oakland, CA 94612
150 Frank H. Ogawa Plaza, Suite 4340, Oakland, CA 94612
Call or email us if you have any questions:
Call or email us if you have any questions:
Call or email us if you have any questions:
Call or email us if you have any questions:
Senior Companion Program:
Senior Companion Program:
Senior Companion Program:
Senior Companion Program:
Taxi Up & Go Project:
Taxi Up & Go Project:
Taxi Up & Go Project:
Taxi Up & Go Project:
Liz Hillen (510) 238
Liz Hillen (510) 238- - - - 3620
Liz Hillen (510) 238
Liz Hillen (510) 238
3620
3620
3620
April Haley
April Haley
April Haley
April Haley (510) 238
(510) 238
(510) 238
(510) 238- - - - 3175
3175
3175
3175
* Projects Funded by Corporation for National & Community Service; Alameda County Commission on Transportation;
FOR OFFICE STAFF ONLY:
ACCEPTED INTO TUGO ON _____/_____/_____ ASSIGNED TO SCP VOLUNTEER _______________________ ON _____/_____/______
REFERRED TO AGENCY/PROGRAM ________________________________________________________ ON ______/______/_________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal