The Dishes Program Dishes Intake Form Registration Step 1 of 2 50% The Dishes Program Intake Form To be eligible for The Dishes Program, you must: Be 60 years of age or better Be the spouse of an eligible participant regardless of age DISCLAIMER: Please be aware, completing this intake form or meeting the eligibility criteria above does NOT guarantee acceptance into The Dishes Program. Acceptance into the program is based on capacity. Once you complete the intake form, you will receive a notice via mail in 5-10 business days with the status of your application. Disclaimer Statement(Required) I acknowledge that I have read the disclaimer statement and understand the contents of the statement. Name(Required) First Last Date of Birth:(Required) MM slash DD slash YYYY Phone Number(Required)Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email Please provide an email address if anyEmergency Contact:Name(Required) Relationship(Required) Phone(Required) How did you hear about us? (e.g. TV/radio ad, print ad, word of mouth, community organization, etc) Nutritional Risk Assessment:Please check applicable response for each statement: I have an illness or condition that made me change the kind and/or amount of food I eat.(Required) Yes No Decline to State I eat fewer than 2 meals per day.(Required) Yes No Decline to State I eat few fruits or vegetables or milk products.(Required) Yes No Decline to State I have 3 or more drinks of beer, liquor or wine almost every day.(Required) Yes No Decline to State I have tooth or mouth problems that make it hard for me to eat.(Required) Yes No Decline to State I don't always have enough money to buy the food I need.(Required) Yes No Decline to State I eat alone most of the time.(Required) Yes No Decline to State I take 3 or more different prescribed or over-the-counter drugs a day.(Required) Yes No Decline to State Without wanting to, I have lost or gained 10 pounds in the last 6 months.(Required) Yes No Decline to State I am not always physically able to shop, cook and/or feed myself.(Required) Yes No Decline to State Social Connection SurveyHow often do you feel that you lack companionship?(Required) Hardly Ever Some of the Time Often Declined to State How often do you feel left out?(Required) Hardly Ever Some of the Time Often Declined to State How often do you feel isolated from others?(Required) Hardly Ever Some of the Time Often Declined to State Food Security SurveyThe food that I bought just didn't last, and I didn't have money to get more.(Required) Often True Sometimes True Never True Declined to State I couldn't afford to eat balanced meals(Required) Often True Sometimes True Never True Declined to State In the last 12 months, did I cut the size of my meals or skipped meals because there wasn't enough money for food.(Required) Yes No Declined to State If you answered YES to the previous question, how often did this happen? Almost Every Month Some Months but Not Every Month Only 1-2 Months Declined to State In the last 12 months, did I ate less than I felt I should because there wasn't enough money for food(Required) Yes No Declined to State In the last 12 months, I was hungry but didn't eat because there wasn't enough money for food.(Required) Yes No Declined to State Meals on Wheels by ACC is required by a new state law to ask individuals receiving our services additional questions for reporting purposes only. We are requesting a few minutes of your time to answer the following questions. Please know: The information shared is not used to determine eligibility. Your responses are voluntary and not required. Your information will remain confidential and protected as required by law. You are free to respond “Decline to state” but your information would be helpful. 1. Please share you race: (please check all that apply)(Required) American Indian or Alaskan Native Asian Indian Black or African American Cambodian Chinese Filipino Guamanian Hawaiian Japanese Korean Laotian Samoan Vietnamese White White - Foreign Born Black or African American and White Asian and White American Indian and White American and Black Other Asian: Other Pacific Islander Other Multi Racial: Decline to State (Race) Decline to State 2. Please share your ethnicity:(Required) Hispanic/Latino Not Hispanic/Latino Decline to State 3. What is your living arrangement?(Required) Lives Alone Does not live Alone # in household:(Required) Decline to State (living arrangement) Decline to State Is your head of household:(Required)SeniorFemaleDisabledDecline to State4. Is your entire household monthly income (over or under?) Household monthly income (over or under?)(Required) Over Under Over / Under(Required)$1,775 a month/ per 1 person household$2,027 a month /per 2 person household$2,280 a month / per 3 person household$2,532 a month/ per 4 person household$2,737 a month /per 5 person household$2,940 per 6 person household$3,143 per 7 person household$3,345 per 8 person household$3,546 per 9 person household$3,833 per 10 person householdHidden$ / month(Required) HiddenDecline to State (Monthly Income) Decline to State 5. What was your sex at birth? (please check all that apply)(Required) Male Female Decline to State 6. What is your gender? (please check all that apply)(Required) Male Female Transgender Female to Male Transgender Male to Female Genderqueer/Gender Non Binary Not Listed Decline to State (Gender ) Decline to State 7. How do you describe your sexual orientation or sexual identity? (please check all that apply)(Required) Bisexual Gay/Lesbian/Same-gender Loving Straight/Heterosexual Questioning/Unsure Not Listed: Decline to State (Sexual Orientation/ Identity) Decline to State 8. Is English your primary language? (please check )(Required) Yes No If not, what is you primary language? Need Translation?(Required) Yes No 9. Are you or your spouse a Veteran? (please check all that apply)(Required) Self Spouse Does not apply Meals on Wheels by ACC thanks you for your responses and time. I understand that the information I am providing on this form is for registration purposes. I understand it will be kept confidential and that it may be used to identify other services for which I qualify or need.Signature of participant or person completing form on their behalf(Required) Date(Required) Participant Rights and Responsibilities Participants Rights To be treated in a fair and equitable manner. If you feel you have not been treated fairly, you may contact Meals on Wheels by ACC at (916) 444-9533. To be spoken to in a polite and professional manner. If accepted into the program, to participate in the Dishes Program and obtain a nutritious meal, engage in socialization, educational, and recreational activities if and when available. To obtain information on the other programs or services within the scope of the Meals on Wheels by ACC’s knowledge and abilities. To not be denied a meal if a monetary donation is not made. Participants Responsibilities To treat Meals on Wheels by ACC staff, facility staff, administration staff, vendors, volunteers, and other patrons with dignity and respect. To not engage in verbal/physical harassment of Meals on Wheels by ACC staff, facility staff, administration staff, vendors, volunteers, and other patrons to include abusive language and/or inappropriate physical contact. To truthfully represent eligibility to obtain services provided by Meals on Wheels by ACC. To be free from the influence of drugs or alcohol. To maintain appropriate personal hygiene that is not offensive to other participants. To wear appropriate clothing such as clean pants, shorts, skirts, dresses, shirts, blouses, and/or shoes. To not remove from any of our restaurant partners any items not belonging to you such as utensils, plates, bowls, program documents, etc; to not use restaurant supplies for personal use. Failure to comply with “Participant Responsibilities” may result in Meals on Wheels by ACC staff and/or restaurant vendor staff exercising their right to refuse service, with a follow-up investigation of the situation by Meals on Wheels by ACC staff. Continued non- adherence to these provisions may result in suspension or termination of service.Participant Responsibility(Required) I have read and agree to abide by the Participant Rights and Responsibilities.