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Are you the spouse of another participant?
Do you receive Medicaid?
1 Person Monthly Income
2 Person Monthly Income


In case of an emergency, whom shall we notify?


Please answer all of the following questions. The purpose is to gather basic characteristics about the people we serve. Answering the questions will NOT affect your eligibility for receiving services

Are you a USA Veteran?
Are you?
Do you live alone?
Do you consider yourself frail/disabled?
A person who has a physical or mental disability which substantially limits one or more life activities
Do you use a wheelchair

I consent to the Erie County Department of Senior Services saving personal information provided by me or my authorized representative in the Statewide Client Data System maintained by the New York State Office for the Aging. This personal information may include, but is not limited to, medical records, employment records, government records, and any other information collected from me by Erie County Department of Senior Services.

I understand that this information is being collected to help in providing services and to identify other services which I may benefit from. I understand that the authority to provide these services and to collect my information for these purposes is found in the Older Americans Act and the New York State Elder Law.

I understand that, consistent with New York State's Personal Privacy Protection Law, my personal information will be treated as confidential and will not be disclosed without my further informed consent for disclosure.

I acknowledge that informed consent has been explained to me and that I understand the need for the information being recorded and that there are laws and regulations protecting the confidentiality of authorized information.

I understand that signing this authorization is voluntary. Refusal to do so may make it difficult to make referrals on my behalf. I have the right to revoke this authorization at any time, except to the extent that action has already been taken based upon this authorization, by writing to Erie County Department of Senior Services.

Electronic Signature Agreement

By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.