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Outreach Services for Seniors

Information Sheet​

Contact Information

In Case of Emergency Contacts

Contact 1

Contact 2

Demographic Information

Medical Information:

Please list any important medical information, such as allergies or diabetes that we need to be aware of in case of an emergency.

Disclosure Statement

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.

Privacy Notice

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.

Consent for Release of Information

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.