6727 Contreras Road, OH 45056
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Please list any important medical information, such as allergies or diabetes that we need to be aware of in case of an emergency.
The Client Registration Form was developed to assist the Council on Aging to monitor the
effectiveness of senior programs offered to the citizens of Ohio. Any client information obtained from
this form will be kept confidential and no personal identifying information about a client (i.e. name,
address, telephone number, etc…) will be released to the public without the client’s prior written
consent, or unless otherwise required under federal law.
The data collected (i.e. age, sex, race, etc.) will be forwarded to the Council on Aging and summarized
and reported to the Ohio Department of Aging (ODA) and the Administration on Aging (AOA) in order
to keep both state and federal legislators informed on the effectiveness of senior programs (as
required by the Older Americans Act reauthorization). While all clients receiving services under the
Older Americans Act are asked to complete the attached form in full, no client may be denied services
for refusing to provide any of the information requested, including Social Security number.
If you have any questions, ask a staff member to explain why this is necessary.
The above health information will only be used or disclosed to provide you with treatment and
services in the case of illness or injury that occurs while on a trip.
I agree to release from liability, MKOSS staff and volunteers for any injury or illness accidentally
incurred by me. First aid may be administered by a competent person. In the event of an emergency, I
hereby give permission to the person in charge to send me to a physician or hospital, as required.
I authorize the MKOSS to share information obtained in the assessment process and updates with
other professional agencies for the purpose of planning services to meet my needs, including both
personal and medical files. I also understand that I can revoke this consent at any time by calling
Social Services at 984-1234. My signature further indicates that I have read or had read and explained
to me this consent and the information to be released.