Tips for Completion of the Russell Mercier Senior Center Registration Form

Tips for Completion of Form 5- Consumer Registration Form
I. SAMS Details- Personal
f. SSN- This form requests the last four digits of your Social Security
number only; if you wish, you may choose to enter four zeroes
g. Default Agency- Enter NCAAA (North Central Area Agency on
Aging)
IV. Assessment Form- Demographics (continued)
d. Income- You may choose to check “Unknown”
Please be sure to sign the Form 5- Consumer Registration Form, where indicated.
Supplement to Form 5- Consumer Registration form:
Medical Conditions: If none, please check “None”
Allergies: If none, please check “None”
This information is collected for reporting to our current and future funding
sources and is useful for the Senior Center to have, especially during an
emergency.