Show/Hide

HELP:

The Hanover Township Food Pantry is run solely on donations from the community and financial contributions to the Hanover Township Foundation. Make a donation today! www.paypal.me/HanoverTownship

Data Page - English

Print
Press Enter to show all options, press Tab go to next option
Please correct the field(s) marked in red below:

Hanover Township Blue Logo – Aging Services

DATA PAGE

Mar. 2020 - Dec. 2020

[Information is used for grant reporting and statistical purposes only and all information is confidential.]

Please direct my Data Page to:
 *
Please direct my Data Page to:
Name
 *
Name
Date of Birth
 *
Address
 *
Address
Township
Township
Phone
 *
Email
Emergency Contact
Emergency Contact
Sexual Identity
 *
Sexual Identity
Are you a Veteran?
Are you a Veteran?
Assistive Device (if used):
Assistive Device (if used):
Ethnicity:
 *
Ethnicity:
Race (check all that apply):
Race (check all that apply):
I live alone.
 *
I live alone.
Income Status
 *
Income Status
 1. Have you made any changes in lifelong eating habits because of health problems? 
 *
1. Have you made any changes in lifelong eating habits because of health problems?
2. Do you eat less than 2 meals per day? 
 *
2. Do you eat less than 2 meals per day?
3. Do you eat fewer than five servings (1/2 cup each) of fruits or vegetables every day? 
 *
3. Do you eat fewer than five servings (1/2 cup each) of fruits or vegetables every day?
4. Do you eat fewer than two servings of dairy products (such as milk, yogurt, or cheese) every day? 
 *
4. Do you eat fewer than two servings of dairy products (such as milk, yogurt, or cheese) every day?
5. Have there been times when you did not have enough money to buy food? 
 *
5. Have there been times when you did not have enough money to buy food?
6. Do you have trouble eating well due to problems with chewing/swallowing?
 *
6. Do you have trouble eating well due to problems with chewing/swallowing?
7. Do you eat alone most of the time? 
 *
7. Do you eat alone most of the time?
8. Without wanting to, have you lost or gained 10 pounds in the last 6 months? 
 *
8. Without wanting to, have you lost or gained 10 pounds in the last 6 months?
9. Have there been times when you were unable to shop, cook or feed yourself? 
 *
9. Have there been times when you were unable to shop, cook or feed yourself?
10. Do you have 3 or more drinks of beer, liquor or wine almost every day? 
 *
10. Do you have 3 or more drinks of beer, liquor or wine almost every day?
11. Do you take 3 or more different prescribed or over-the-counter drugs per day?
 *
11. Do you take 3 or more different prescribed or over-the-counter drugs per day?
HTlogo

Hanover Township does not discriminate in admission to programs or activities or treatment of employment in programs or activities in compliance with the Illinois Human Rights Act, the U.S. Civil Rights Act, the U.S. Civil Discrimination Act, the Aged Discrimination in Employment Act, the U.S. and Illinois Constitutions. If you feel you have been discriminated against, you have a right to file a complaint. For information, contact Tracey Colagrossi, Director, Aging Services at (630) 483-5600. 

age options

 AgeOptions does not discriminate in admission of programs or treatment of employment in programs or activities in compliance with the Illinois Human Rights Act; the U.S. Civil Rights Act; Section 504 of the rehabilitation Act; the Age Discrimination act; the Age Discrimination in Employment Act; and the U.S. and Illinois Constitution. If you feel that you have been discriminated against, you have the right to file a complaint with the Illinois Department on Aging. For information; call 1-800-252-8966 (Voice and TDD) or contact the AgeOptionsCivil Rights Coordinator at (708) 383-0258.

 

  1. To receive a copy of your submission, please fill out your email address below and submit.
    CAPTCHA
    Change the CAPTCHA codeSpeak the CAPTCHA code