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Care Receiver Application
Care Receiver Application
Faith in Action of Marathon County, Inc.
100 N. 72nd Ave, Suite 227 | Wausau, WI | 54401
Ph# 715.848.8783 | Website: faithinactionmarathoncounty.org
Email: wausaufiainfo@gmail.com
All Services are Provided regardless of Income | Religious Beliefs | Race | Ethnic Background
Please allow
2-3 weeks
for a Home Visit to be scheduled
Faith in Action of Marathon County, Inc. is a non-profit organization with partial funding of our offering coming from grants. Certain demographic information is needed on many grants, so we would ask for your cooperation in providing the following information.
Please be assured all personal information will be kept strictly confidential.
General
Personal Information
First Name
*
*
Middle Initial
*
Last Name
*
*
Primary Email
*
*
*
Home Phone
*
Cell Phone
*
*
Opt-in to Text Messages
*
Opt-in to Text Messages
No
Opt-in to Text Messages
Yes
Do you consent to having your picture taken by a staff member or volunteer?
*
Do you consent to having your picture taken by a staff member or volunteer?
No
Do you consent to having your picture taken by a staff member or volunteer?
Yes
Additional Information
Date of Birth
*
*
Approx. Weight (lbs)
*
*
*
Gender
*
Female
Male
Race
*
American Indian/Native Alaskan
Asian
Black / African American
Native Hawaiian / Pacific Islander
White
Two or more races
Unknown
Prefer Not to Say
Ethnicity
*
Hispanic
Non Hispanic
White / Caucasian
Other
Marital Status
*
Single
Married
Divorced
Widowed
Civil Union
Domestic Partnership
Languages Spoken
*
Other Languages
*
Residence Information
Street 1
*
*
Street 2
*
City
*
*
State/Province
*
*
Zip/Postal Code
*
*
Residence Information2
Type of Dwelling
Single Family
Multi-Family
Condo
Apartment Building
Nursing Home
Do You Rent or Own Your Residence?
Own
Rent
Living Arrangements
Alone
With Spouse
Other
Do You Have Access to a Computer?
Do you currently drive?
How Did You Hear About Us?
*
Advertising / Marketing Solicitation
Aging Disability Resource Center
Family / Friend
Medical Profession (Chiropractor, Doctor, Dentist)
Publication (Newspaper, Magazine, TV Ad)
Religious Organization
Social Media (Facebook)
United Way / "211" website
Other
Mental Health / Health Status
Do You Have Any Cognitive Health Concerns?
Do You Have Any Physical Health Concerns?
Cognitive Heath Concerns
*
Physical Health Concerns
*
Mobility
Use a Cane?
Does the Walker or Wheelchair Fit in Truck of Mid-size Car?
Use a Walker?
Are You Able to Comfortably Enter and Exit a Mid-size Car?
Use a Wheelchair?
Have Any Physical Health Conditions That Affect Mobility (Please Describe)?
*
Other Info A Volunteer Should Know for Safe Transport
*
Social Involvement
Do You Have Social Contact With Others?
Do You Attend Any Religious Organizations (Please Describe)?
*
Do You Participate In Community Activities (Please Describe)?
*
Receive Help from Relatives or Others (Please Describe)?
*
Financial Information
Size of Household
1
2
3
4
5
6
Select Household Monthly Income Range
1,304 - 1,733
1,734 - 1798
1,799 - 1,955
1,956 - 2,607
2,608 - 3,911
3,912 +
Select Household Monthly Income Range
1,762 - 2,343
2,344 - 2,431
2,432 - 2,642
2,643 - 3,524
3,525 - 5,286
5,287 +
Select Household Monthly Income Range
2.220 - 2.952
2,953 - 3,063
3,064 - 3,330
3,331 - 4,440
4,441 - 6,661
6,662 +
Select Household Monthly Income Range
2.679 - 3.562
3,563 - 3,696
3,697 - 4,017
4,018 - 5,357
5,358 - 8,036
8,037 +
Select Household Monthly Income Range
3,137 - 4,171
4,172 - 4,328
4,329 - 4,705
4,706 - 6,274
6,275 - 9,411
9,412 +
Select Household Monthly Income Range
3,595 - 4,781
4,782 - 4,961
4,962 - 5,392
5,393 - 7,190
7,191 - 10,786
10,787 +
Emergency Contact #1
First Name
*
*
Middle Initial
*
Last Name
*
*
Relationship To You
Husband
Wife
Aunt
Brother
Case/Social Worker
Cousin
Daughter
Employer
Ex-Spouse
Father
Friend
Granddaughter
Grandfather
Grandmother
Grandson
In-law
Lawyer
Legal Guardian
Life Partner
Mother
Nephew
Niece
Other
Parent
Significant Other
Sister
Son
Spouse
Step Father
Step Mother
Uncle
Unknown
Ward of the Court
Email
*
*
*
Home Phone
*
Cell Phone
*
*
Street 1
*
*
Street 2
*
City
*
*
State
*
*
Zip Code
*
*
Emergency Contact #2
First Name
*
Last Name
*
Relationship To You
Husband
Wife
Aunt
Brother
Case/Social Worker
Cousin
Daughter
Employer
Ex-Spouse
Father
Friend
Granddaughter
Grandfather
Grandmother
Grandson
In-law
Lawyer
Legal Guardian
Life Partner
Mother
Nephew
Niece
Other
Parent
Significant Other
Sister
Son
Spouse
Step Father
Step Mother
Uncle
Unknown
Ward of the Court
Middle Initial
*
Email
*
*
Home Phone
*
Cell Phone
*
Street 1
*
Street 2
*
City
*
State
*
Zip Code
*
Needs
Services Requested
Companionship Phone Call or Visit
*
No
Yes
Phone Call / Visit Frequency
*
Weekly
Bi-Weekly
Monthly
Other
N/A
Food Pantry Delivery (Twice a Month)
*
No
Yes
Grocery Shopping
*
No
Yes
Grocery Shopping Frequency
*
Weekly
Bi-Weekly
Monthly
Other
N/A
Grocery Delivery
*
No
Yes
Grocery Delivery Frequency
*
Weekly
Bi-Weekly
Monthly
Other
N/A
Medical Appointments Transportation
*
No
Yes
Medical Appointment Frequency
*
Weekly
Bi-Weekly
Monthly
Other
N/A
Non-Medical Appointments Transportation
*
No
Yes
Non-Medical Appointment Frequency
*
Weekly
Bi-Weekly
Monthly
Other
N/A
Wellness Checks
*
No
Yes
Wellness Checks Frequency
*
Weekly
Bi-Weekly
Monthly
Other
N/A
Additional Community Resources
Addiction Help
Employment
Benefits / Financial Advice
Family Care-Giver Support
Blood Pressure Screening
Legal Assistance
Housekeeping and Simple Meal Prep
Educational Resources
Mental Health Assistance
Elder Abuse Resources
Emergency Alert Services
Prescription Drug Help
Background Check Information
Have Any Criminal Charges Pending Against You?
*
No
Yes
Explain Criminal Charges If Any
*
Lived Outside of WI in the Last 3 Years
*
No
Yes
If Yes, List State and Dates You Lived There
*
Please List Your Name If You Are Filling this Out On Behalf of the Applicant
First Name
*
Last Name
*
Relationship to Applicant
Husband
Wife
Aunt
Brother
Case/Social Worker
Cousin
Daughter
Employer
Ex-Spouse
Father
Friend
Granddaughter
Grandfather
Grandmother
Grandson
In-law
Lawyer
Legal Guardian
Life Partner
Mother
Nephew
Niece
Other
Parent
Significant Other
Sister
Son
Spouse
Step Father
Step Mother
Uncle
Unknown
Ward of the Court
Please Read the Confidentiality Agreement Below and Check the Box If you Agree
Your Consent to Use Electronic Signature and Electronic Delivery of Documents or Communications. By clicking “I Agree” at the bottom of this page, you consent to use your electronic signature to sign any document or communication and to receive electronic delivery of any document or communication. You understand that your electronic signature is legally binding, just as if you had signed a paper document. You further agree that your computer or other device satisfies applicable hardware and software requirements and that you have provided FIAMC with a current email address at which we may send you electronic records and communications. Volunteers are instructed not to share your name or any information about you that would identify you to persons not involved with your care without your permission. To help us meet your needs, we request you give permission to authorize program staff, community agencies, and volunteers about your health status, history, and current needs, to provide you with the best service possible. I understand the screening requirements mentioned above and authorize Faith In Action of Marathon County, Inc. to conduct a National Criminal Background check. I understand under penalty of law, the information provided above is truthful and accurate to the best of my knowledge and that knowingly providing false information or omitting information may result in a forfeiture of up to $1,000.00 and other sanctions as provided in HFS 12.05 (4), Wis. Adm. Code.
I Agree
*
Date of Signature
*
*
