Friendly Assurance Program Application

Consent for storing submitted data

Must be 60 years of age or older to participate

Yes, I give permission to store and process my data

Date

Client Registration Type

Care Recipient

Caregiver

Date of Birth

First Name

Middle Initial

Last Name

Street Address

City

State

Zip Code

Mailing Address (if different)

County of Residence

Township of Residence

Telephone

E-mail

Gender

Female

Male

Other

Prefer not to say

Unknown

Do you consider yourself to be transgender or gender non-conforming?

Yes

No

Unknown

Does client live alone?

Yes

No

Unknown

Client Sexual Orientation

Straight/Heterosexual

Lesbian

Gay

Bisexual

Prefer not to say

Other

Unknown

Household Size

Two People

Three People

Four or More People

Ethnic Origin/Race

White

Black/African American

American Indian/Alaskan Native

Asian

Native Hawaiian/Other Pacific Islander

Unknown

Is the client Hispanic?

Yes

No

Uknown

Is the client multi-racial

Yes

No

Unknown

If client is multi-racial (check all that apply):

White

Black/African American

American Indian/Alaskan Native

Asian

Native Hawaiian/Other Pacific Islander

Unknown

Is client below poverty?

Yes

No

Unknown

Does client speak language other than English at home? If yes, enter language

How well does the client speak English?

Very well

Well

Not well

Not at all

Unknown

Has the client ever served on active duty in the U.S. Armed Forces, Reserves or National Guard?

Yes

No

Unknown