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Erie County Program Registration Form
Hello! Thank you for participating in University Express! We are instituting an official registration process for the program. This will help ensure that we are receiving credit for all the participants we serve, thus sustaining the program. This will also help create a contactless sign-in process at our participating locations. This registration form does not need to be completed if you are already registered with the Stay Fit Dining Program or Club 99, as your key tag will work for any Senior Services program that uses a scanner. Once you have completed this webform, you can expect to receive a key tag in the mail in the spring. Your key tag will be used to swipe in for your attendance at our participating locations. This will be more efficient and effective. We appreciate your understanding and support as we continue to improve our program and ensure its longevity! Please contact the Coordinator Katie Earl at 858-7605 if you have any questions.
First Name
Last Name
Address
City/Town/Village
State
Zip Code
Phone Number
Email Address
Are you interested in receiving emails about Erie County Department of Senior Services programs?
Yes
No
Date of Birth
Veteran
Yes
No
Living Status
Alone
With spouse/partner only
With spouse/partner and others
With relatives
With non-relatives
Other
Marital Status
Married
Widowed
Divorced
Never married
Domestic partner or significant other
Race
White
Black or African American
American Indian/Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Two or more races
Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Primary Senior Center Attended
Emergency Contact Name
Emergency Contact Relationship
Emergency Contact Phone Number
Informed Consent to Capture and Record Personal Information
I hereby consent to my personal information contained in the online registration form being saved in the Client Data System maintained by the New York State Office for the Aging and used by the local Office for the Aging. I understand that my information will not be shared with other agencies without my permission.
I understand that the information on this form may be sent to the State and Federal Government, and is used to improve the services offered and better meet my needs.
Signature
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