Nutrition Program Congregate Meal Registration Form
The congregate meal program is funded with State and Federal dollars and participants who receive this service are asked to complete this registration form and the nutritional survey on the backside.

This helps the Idaho Commission on Aging and your local Area Agency on Aging understand the nutrition needs in your community and builds a comprehensive network of seniors.

PLEASE COMPLETE ALL FIELDS IN THIS BOX

Last Name

First Name

Middle Initial or Nickname

Address

Zip Code

E‐Mail Address

Telephone Number

	/	/	
Date of Birth

If you are under 60:
☐	Spouse of participant over 60
☐	Person with disability living with someone over 60
☐	Volunteering during mealtime under 60
☐	Person residing in a housing facility where Congregate Meals are served

Attestation of Lawful Presence in the United States:
Under penalty of perjury, the consumer attests to being a United States citizen, or legal permanent resident, or is otherwise lawfully present in the United States pursuant to federal law.
Date of Consumer attestation: _________________            
Demographic Information:
Marital Status: ☐Married ☐Single ☐Widowed ☐Divorced

Living alone:	☐Yes ☐No	Gender: ☐Male ☐Female	Veteran: ☐Yes ☐No Number of household members: 	
Estimated Annual Household Income: $	

Ethnicity:  ☐ Hispanic or Latino ☐Not Hispanic or Latino
Race:
☐American Indian or Alaska Native ☐Asian or Asian American ☐White
☐	Black or African American ☐Native Hawaiian or Pacific Islander 

Emergency Contact: 	 Phone Number: 	

Reset Form

FO_NU_02 Congregate Meal Registration Form and Nutritional Health Risk Survey 07/28/2025. Previous editions are obsolete.

DETERMINE YOUR NUTRITIONAL HEALTH

The Warning Signs of poor nutritional health are often overlooked. Use this Checklist to find out if you or someone you know is at nutritional risk.

Read the statements below. Circle the number in the “yes” column for those that apply to you or someone you know. For each “yes” answer, total the numbers in the box.
Total your nutritional score.	Yes	
I have an illness or condition that made me change the kind and/or amount of food I
eat.	2	
I eat fewer than 2 meals per day	3	
I eat few fruits or vegetables or milk products	2	
I have 3 or more drinks of beer, liquor or wine almost every day.	2	
I have tooth or mouth problems that make it hard for me to eat.	2	
I don’t always have enough money to buy the food I need.	4	
I eat alone most of the time.	1	
I take 3 or more different prescribed or over‐the‐counter drugs a day.	1	
Without wanting to, I have lost or gained 10 pounds in the last 6 months.	2	
I am not always physically able to shop, cook and/or feed myself.	2	
Total your nutrition score:		

Total your nutrition score and if it is:
0‐2: Good! Re‐check your nutritional score every 2 years or sooner, if things change.
3‐5: You are at moderate nutritional risk. See what can be done to improve your eating habits and lifestyle.
6 or more: If you are at risk and would like to benefit from free nutrition counselling, please contact your meal site coordinator, who will refer you to a qualified Dietitian.

Remember that Warning Signs suggest risk, but do not represent a diagnosis of any condition.
These materials are developed and distributed by the Nutrition Screening Initiative, a project of:

AMERICAN ACADEMY OF FAMILY PHYSICIANS THE AMERICAN,

,

The American Dietetic Association

For AAA only: Fax number: 	
Email: 	
Fax or email completed form by the   of each month.

For Meal‐site only: Meal‐site’s name:

FO_NU_02 Congregate Meal Registration Form and Nutritional Health Risk Survey 05/15/2020. Previous editions are obsolete.