Wheatland, NY · Monroe County
Senior Center Registration Form
This form collects registration, contact, demographic, nutrition screening, and consent information from people enrolling with a senior center.
What this form is
The Senior Center Registration Form records information for the senior center and the Office for the Aging, including contact details, date of birth, emergency contact, and nutrition screening responses. It also includes informed consent and optional authorizations related to referrals and sharing information during an emergency. Complete all sections and print clearly; the date completed must be updated annually.
Who needs it
People registering with a senior center complete this form to provide personal information, request services, and record any consent they choose to give.
How to submit it
Submit it to the city department named on the form; check the city website for current contact details.
About notarization
This form is signed and dated without a notary; its referral and information-sharing authorizations use initials and signatures, not notarization.
How to submit this form
- 1
Download The Form
Download the Senior Center Registration Form.
- 2
Complete The Form
Complete all sections and print clearly. The form asks for personal details, contact information, nutrition screening responses, and service preferences.
- 3
Review Consent Sections
Review the consent and authorization sections, and provide initials or signatures where applicable.
- 4
Submit The Form
Submit it to the city department named on the form; check the city website for current contact details.
Frequently asked questions
- Who should complete the Senior Center Registration Form?
- People registering with a senior center should complete the form, which requests personal and contact details, emergency contact information, nutrition screening responses, and service preferences.
- Do I need a notary for the Senior Center Registration Form?
- No. The form is signed and dated without a notary. Its referral and information-sharing authorizations use initials and signatures, not notarization.
- How do I submit the Senior Center Registration Form?
- The form does not state how or where to submit it. Submit it to the city department named on the form; check the city website for current contact details.