DATA PAGE

Oct. 2024 - Sep. 2025

[Information is used for grant reporting and statistical purposes only and all information is confidential.]

Please direct my Data Page to: (check all that apply)

Please direct my Data Page to: (check all that apply)

Nutrition

Programming

Social Services

Transportation

Volunteers

Name

 *

Name

Last Name

First Name

Nickname

Date of Birth

 *

Date of Birth

Address

 *

Address

Street Address

City

Zip

Township

Township

Hanover Township	Bloomingdale Township	Elgin Township
Schaumburg Township	St. Charles Township	Wayne Township
Other If other, type text here.

Phone (If you only have a cell phone, please add that number for both Home and Cell)

 *

Phone (If you only have a cell phone, please add that number for both Home and Cell)

Home Phoneext.

Cell Phoneext.

Email

Email

Sexual Identity

 *

Sexual Identity

Male

Female

Other:

Marital Status:

Marital Status:

Married	Divorced	Single
Widowed	Legally Separated	Domestic Partner

Are you a Veteran?

Are you a Veteran?

Yes

No

Assistive Device (if used):

Assistive Device (if used):

Cane	Standard Walker
Walker with Seat	Wheelchair
Motorized Scooter	Service Animal
Oxygen	Other:

Emergency Contact

Emergency Contact

Name	Relationship	Home Phone
Cell Phone	Work Phone

Ethnicity:

 *

Ethnicity:

Hispanic

Non-Hispanic

Race (check all that apply):

Race (check all that apply):

White	Black or African American
American Indian or Alaska Native	Asian
Native Hawaiian or Other Pacific Islander	Other Race:

I live alone.

 *

I live alone.

Yes

No

Income Status

 *

Income Status

I live alone. My monthly income is more than $1,255.

I do NOT live alone. My monthly income is more than $1,703.

None of the above

Are you limited in understanding and speaking English?

 *

Are you limited in understanding and speaking English?

Yes

No

If "Yes" what is your primary language:

I have an illness or condition that has made me change the kind or amount of food I eat.

 *

I have an illness or condition that has made me change the kind or amount of food I eat.

Yes

No

I eat less than 2 meals per day.

 *

I eat less than 2 meals per day.

Yes

No

I eat few fruits and vegetables, or milk products. 

 *

I eat few fruits and vegetables, or milk products.

Yes

No

I have three or more drinks of beer, liquor or wine almost every day.

 *

I have three or more drinks of beer, liquor or wine almost every day.

Yes

No

I have tooth or mouth problems that make it hard for me to eat.

 *

I have tooth or mouth problems that make it hard for me to eat.

Yes

No

I don't always have enough money to buy the food I need.

 *

I don't always have enough money to buy the food I need.

Yes

No

I eat alone most of the time.

 *

I eat alone most of the time.

Yes

No

I take three or more different prescribed or over-the-counter drugs a day.

 *

I take three or more different prescribed or over-the-counter drugs a day.

Yes

No

Without wanting to, I have lost or gained ten pounds in the last six months.

 *

Without wanting to, I have lost or gained ten pounds in the last six months.

Yes

No

I am not always physically able to shop, cook, and/or feed myself.

 *

I am not always physically able to shop, cook, and/or feed myself.

Yes

No

Do you currently receive food assistance benefits? (Examples: SNAP, SFMNO, TEFAP)

 *

Do you currently receive food assistance benefits? (Examples: SNAP, SFMNO, TEFAP)

Yes

No

Do you currently receive meal assistance from another source (i.e. food pantry, family)?

 *

Do you currently receive meal assistance from another source (i.e. food pantry, family)?

Yes

No

Do you have difficulty chewing/poor dental health?

 *

Do you have difficulty chewing/poor dental health?

Yes

No

Do you have difficulty swallowing?

 *

Do you have difficulty swallowing?

Yes

No

Do you have special diet needs? (If yes, please specify below)

Do you have special diet needs? (If yes, please specify below)

Diabetic	Low Sodium	Vegetarian
Other:

 Authorization of Release of Information

 *

I give permission to the provider and/or the Area Agency on Aging Staff to discuss my needs.

Hanover Township does not discriminate in admission to programs or activities or treatment of employment in programs or activities in compliance with the Illinois Human Rights Act, the U.S. Civil Rights Act, the U.S. Civil Discrimination Act, the Aged Discrimination in Employment Act, the U.S. and Illinois Constitutions. If you feel you have been discriminated against, you have a right to file a complaint. For information, contact Megan Conway, Director, Aging Services at (630) 483-5671. 

 AgeOptions does not discriminate in admission of programs or treatment of employment in programs or activities in compliance with the Illinois Human Rights Act; the U.S. Civil Rights Act; Section 504 of the rehabilitation Act; the Age Discrimination act; the Age Discrimination in Employment Act; and the U.S. and Illinois Constitution. If you feel that you have been discriminated against, you have the right to file a complaint with the Illinois Department on Aging. For information; call 1-800-252-8966 (Voice and TDD) or contact the AgeOptions Civil Rights Coordinator at (708) 383-0258.

 

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