Member Sign-Up

By registering, you're helping to keep Bugbee Membership free for all older adults! Attendance and community demographics are important for our funding sources and program development. Your information is kept strictly confidential and is only accessed by authorized staff and agency partners.

Your Information:

First Name

Middle Initial

Last Name

Your Birthdate

Check here if you would like to keep your date of birth private, and we won’t recognize your birthday in public.

Are you a veteran?

Yes

Gender

Male

Female

Other

Marital Status (please check one):

Single

Married

Widowed

Divorced

Separated

Domestic Partner

Your Contact Information:

Home Phone

Cell Phone

Your Email

How would you like to receive the monthly Bugbee Bulletin?

To my mailing address

Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

Physical address (if different from mailing address):

Household:

I live alone

I live with someone/others

Other Information:

Disabilities, allergies, accessibility requests:

Emergency Contact Information (provide up to 2 contacts):

Name	Relation	Phone

May we use photos of you in our publicity materials?

Do you plan on attending or taking out meals at Bugbee within the following year?

Yes/Maybe

Senior Solutions is our Area Agency on Aging, and they provide provide partial funding for your meals at Bugbee when you complete the rest of this form. By taking just an extra minute for these last few questions, it helps keep the suggested donation low for everyone, and it means we can serve more meals!

Community Meals Sign Up

Thank you for completing this document which collects information that is required for state and federal financial support of your meals. You only need to complete this form once per year, no matter how many meals or meal sites you attend.

Senior Solutions • 38 Pleasant Street, Springfield, VT 05156
www.seniorsolutionsvt.org • [email protected] • 802-885-2655

Race (please check all that apply):

White/Caucasian

Indigenous/Native American

Asian

Black/African American

Native Hawaiian/Other Pacific Islander

Latino

Unknown/Prefer Not to Answer

Ethnicity (please check one):

Not Hispanic or Latino

Hispanic or Latino

Unknown/Prefer not to answer

How many people live in your household, including yourself?

One Person

Two People

Three+ People

Please check the box in the table below that best represents your usual combined monthly income, for the number of people living in your home.

	Under $1,330	$1,330 or more
One Person

Please check the box in the table below that best represents your usual combined monthly income, for the number of people living in your home.

	Under $1,804	$1,804 or more
Two People

Please check the box in the table below that best represents your usual combined monthly income, for the number of people living in your home.

	Under $2,277	$2,277 or more
Three+ People

Please answer to the best of your ability.

	Yes	No
Have you made any changes in lifelong eating habits because of health problems?
Do you eat fewer than two meals per day?
Do you eat less than five (5) servings (1/2 cup each) of fruit or vegetables every day?
Do you eat less than two (2) servings of dairy products (such as milk, yogurt or cheese) every day?
Do you have trouble eating due to problems with chewing/swallowing?
Do you sometimes not have enough money to buy food?
Do you eat alone most of the time?
Do you take three or more different prescribed or over-the-counter medications per day?
Without wanting to, have you lost or gained 10 pounds or more in the past six months?
Are there times when you are not always physically able to shop, cook and/or feed yourself (or to get someone to do it for you)?
Do you have three or more drinks of beer, liquor, or wine almost every day?

Would you like a free consultation with a Senior Solutions Registered Dietician?

Yes, have them call me

No thanks

Welcome!

Your Information:

Your Contact Information:

Other Information:

Community Meals Sign Up