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. 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

Date of Birth

Are you a Veteran?

Yes

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

Signature

Sign above