LINKS Senior Connection Application Senior Connection ApplicationName *Date of Birth *Street Address *Apartment, suite, etcCity *State/Province *ZIP / Postal code *Primary Phone *Work PhoneEmail Address *Person(s) authorized to pick up your child / Emergency Contacts: (Person must show picture I.D.)Emergency Contacts:Name *Relationship *Phone *Primary LanguageEnglishSpanishOtherMedical Care and MedicationsAre you under medical care or taking any medication(s)? *YesNoIf yes, please check all of the following conditions that you have and indicate if medication needs to be dispensed at Events?Bee Sting AllergyYesNoEpi-PenYesNoOther AllergiesAthmaYesNoInhalerYesNoDiabetesYesNoInsulinYesNoOtherSpecial NeedsYesNoDisability:Vision ImpairedYesNoGlassesYesNoHearing ImpairedYesNoFamily Health CarePhysician's NamePhysician's PhonePhysician's AddressApartment, suite, etcCityState/ProvinceZIP / Postal codeMedicaidYesNoHealth Insurance #Program Selection and ConsentDoes the LINKS Community and Family Services have permission to use photos of you in educational or promotional materials?YesNoPlease read and sign below:I understand that this is a FREE program. These services are possible through state grants and district funding.Your Signature *Start signing your signature hereYour browser does not support e-Signature field.Today's Date *MEDICAL INFORMATION & LIABILITY RELEASEPLEASE COMPLETE ALL AREAS.First Name *Last Name *Birth Date *Street Address *Apartment, suite, etcCity *State/Province *ZIP / Postal code *Primary Phone *Cell PhoneEMERGENCY TELEPHONE NUMBERS:Emergency Contact Name *Emergency Contact Phone *MEDICAL INSURANCE CARRIER:Your Insurance Group NameInsurance Group NumberFamily physician’s NameFamily physician’s PhoneDate of Last Tetanus ShotAllergies, conditions, dietary restrictions, special needs, medical concerns of which we should be aware:Food AllergiesDrug AllergiesAnimal AllergiesOther AllergiesI require the following medicineFrequencyI have given permission to be given Tylenol or Ibuprofen if I request it. *YesNoIn the case of a medical emergency I understand that, in the event medical treatment is required, every effort will be made to contact me or the emergency contact person. However, if I cannot be reached, I give permission to the staff to secure the services of a licensed physician to provide the care necessary, including hospitalization, anesthesia, injection, or surgery for my well-being. I hereby agree to indemnify and hold harmless LINKS Community & Family Services, officers, volunteers, employees, and staff from any liability.Your Full Name *Your Signature *Start signing your signature hereYour browser does not support e-Signature field.Today's Date *Enrollment FormEligibility DateNative LanguageFirst Name *Middle Name or InitialLast Name *Birth/Due Date *SexMaleFemaleSSNStreet AddressApartment, suite, etcCityState/ProvinceZIP / Postal codePrimary PhoneCell PhoneEmail AddressRace(s)Must choose 2, if “Unknown” is checked:American Indian or Alaska NativeBlack or African AmericanWhiteFilipinoJapaneseNative HawaiianOthan AsianAsian IndianChineseGuamanian or ChamorroWhiteKoreanOther Pacific IslanderVietnameseSamoanUnknownEthnicityNon-HispanicHispanicMexican/Mexican American/ChicanaOther Hispanic/LatinoCubanPuerto RicanUnknownVerified Eligibility (if applicable)YesNoSourceWICMedicaidBCMHSNAPOtherCase:Do you meet the Household Eligibility Guidelines Effective 12/15/2025YesNoWhat Services/Information would you like?Birth ControlChild DevelopmentClothingDentalDiapersEducationEmploymentFinancialFoodHead Start/PreschoolHealth InsuranceHousingLegalMedicalMental Health ServicesSenior ServicesOtherAnnual Income(1) 31,300.00(2) 42,300.00(3) 53,300.00(4) 64,300.00(5) 75,300.00(6) 86,300.00(7) 97,300.00(8) 108,300.00Monthly Income2,608.003,525.004,442.005,358.006,275.007,192.008,108.009,025.00Weekly Income602.00813.001,025.001,237.001,448.001,660.001,871.002,083.00Select *Select the number from the income chart above that represents your income range12345678For families with more than 8 persons, add $11,000 annually ($917 monthly) for each additional personHow many years of education has the Primary caregiver completed?Enrolled in any kind of school, vocational or educational program?YesNoCurrently working/employed? *YesNoIf YES, place of employment?If NO, are you currently seeking employment?YesNoPlease list everyone who lives in the home, including all non-family members. List primary care giver first.First Name *Last Name *Age *Date of Birth *Male/FemaleLast 4 SSN *Submit
