**Confidential Information**
DIRECTIONS: Print this page and fill it out completely. You will need to turn it into Joe Nemeth or Scott Crawford. This information will be kept confidential. It will be used for the purpose of tracking our grants that the Council on Aging receives to pay for programs like our Technology Instruction. Please print neatly.
Last Name___________________ First Name______________________Mid Int________
Address_______________________City___________________State_________Zip_________
County_____________Township______________
Social Security #____________________(Not Required)
Phone Number( )
Email Address ______________________________
Date of Birth (Required)
Signature
Address_____________________City__________________State_________Zip___________
Gender Male/Female (circle) Lives Alone Yes/No (circle)
Info Below is Voluntary
Race_______________________________
Multiracial___________________________________________(Give Heritage(s))
If your monthly joint income is above $900 per month, circle YES. If it is below $900 per month, circle NO.
YES / NO