<p> TAP Program Member Enrollment Form</p><p>Date: ______General Information</p><p>Name: </p><p>Address (Number & Street): </p><p>City: State: Zip code: </p><p>Home Phone: Cell Phone: </p><p>Date of Birth: Gender: __ Male __ Female </p><p>Race / Ethnicity (please check all that apply):</p><p>__African American __Caucasian __American Indian /Alaskan Native __Asian __Arab American __Native Hawaiian/Pacific Islander </p><p>__Hispanic/Latino __Other </p><p>Sources of Income (please check all that apply):</p><p>__Medicaid __Medicare __Social Security Disability (SSD)</p><p>__Social Security (SS) __Veterans Benefits __Supplemental Security Income (SSI)</p><p>Income Range (information used for funding reporting purposes only, does not determine eligibility):</p><p>__ Below $9,999 __$10,000 - $19,999 __$20-000 - $29,999</p><p>__$30,000 - $39,999 __$40,000 - $49,999 __$50,000 - up</p><p>Do you live alone? __Yes __No</p><p>Personal Information (the following information is used to match interests of volunteers and members)</p><p>Foreign Language Skills: </p><p>Level of Fluency: __Fluent __Able to Read __Some Training</p><p>Marital Status: Religion: </p><p>Hobbies and Interests: ______</p><p>Primary Physician Contact Information</p><p>Name: Office Phone: ______</p><p>Please list any health issues of which the TAP office or the TAP Volunteer should be aware: </p><p>______</p><p>Revised 9/10 Page 1 of 2 TAP Program Member Enrollment Form</p><p>Emergency Contact Information</p><p>Name: Relationship: </p><p>Address (no., street, city, state, ZIP): </p><p>Day Phone: Evening Phone: </p><p>------</p><p>Name: Relationship: </p><p>Address (no., street, city, state, ZIP): </p><p>Day Phone: Evening Phone: </p><p>Program Information</p><p>When do you wish to receive calls?</p><p>Days: __Mon __Tues __Wed __Thurs __Fri __Sat __Sun</p><p>Times: __Morning __Afternoon __Evening</p><p>How many calls would you like to receive each week?___</p><p>I am interested in receiving: (select one or both) __socialization calls; __well-being check calls</p><p>Referral Information</p><p>Name: Relationship: </p><p>Organization: Phone: </p><p>TAP Site Information (to be completed by office staff)</p><p>TAP Site: Coordinator: </p><p>Call Schedule Volunteer’s Name Home Phone Other Phone Call Details (Day & Time)</p><p>Revised 9/10 Page 2 of 2</p>