CHAMPSS Consumer Application Form
三藩市耆英及殘障人仕服務局顧客登記表
Date:
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Before applying for the CHAMPSS program, have you participated in other community senior meal program?
在申請CHAMPSS計劃之前，你是否參加過其他社區長者膳食計劃？
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How did you hear about the CHAMPSS Program?
你如何知道CHAMPSS計劃？ （請提供來源)
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Are you also enrolling a Spouse/Partner under 60?
(你會否登記你的60歲以下配偶/伴侶？)
If yes, Spouse/Partner’s Name?
如果是，配偶/伴侶的名字
Gold Card ID Number (if known)
如果是，配偶/伴侶的名字
Note: If enroll spouse/partner < 60 to CHAMPSS program, please fill out another Application Form.
注意：如果登記你的60歲以下配偶/伴侶到CHAMPSS計劃，請填寫另一份申請表。
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Meal Site (飯堂): “If your application is approved, you must pick up your CHAMPSS card at one of the following locations – please select where you would like to pick up your card. 如果您的申請獲得批准，您必須選擇以下其中一個安老自助處的康樂中心辦公地點領取您的美味營養餐卡。”
All required fields are marked by a red asterisk *
所有標有紅色星號“*
”需填
IDENTIFICATION (身 份 證 明)
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Last Name (姓氏)
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First Name (名字)
Middle Name (中間名字)
AKA Last Name (又姓)
AKA First Name (又名)
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Date of Birth (出生日期)
Last 4 Digits of Social Security Number (工卡號碼 (最后四位))
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Email Address (電郵地址)
(Used by agency to share important information with you)
Are you Homeless? (你是否無家者？)
Address Type (地址類型)
County (縣市)
Apt/Bldg/Suite/Rm#: (公寓/建筑/套房/房间#:)
 
Phone 1: (電話 (1))
Phone 2: (電話 (2))
DEMOGRAPHICS (個 人 資 料)
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What is your gender? (Check one that best describes your current gender identity): (您的性別是？( 選擇一個最符合您目前的性別認同的選項))
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How do you describe your sexual orientation? (Check one that best describes your sexual orientation) : (您如何描述自己的性傾向或性別認同？(請選擇一項))
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Race: (種族)
Edit
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Ethnicity: (民族)
Primary (Main) Language: (主要語言)
English Fluency: (英語程度)
Literacy: (讀寫能力)
Relationship Status: (婚姻狀況)
Employment Status: (職業狀況)
Veteran Status: (退伍軍人狀況)
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Urban/Rural
If you reside in San Francisco, Supervisory District: (管理地區:)
Select "Urban" if you live in San Francisco or in any large city.
Select "Rural" if you live in the countryside or non-metropolitan area.
如果你住在三藩市或其它大城市，請選擇“都市” (urban).
如果你住在鄉村或效外，請選擇“鄉村” (rural).
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Lives With: (居住狀況)
Housing Type: (住房類型)
Primary Transportation: (主要交通工具)
Sources of Support (資助來源)
Poverty Guidelines
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Is your income level at or below 100% Federal Poverty Guidelines (FPL)?
你的收入是否低於100%聯邦貧窮線？
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Is your income level at or below 200% Federal Poverty Guidelines (FPL)?
你的收入是否低於200%聯邦貧窮線？
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Is your income level at or below 300% Federal Poverty Guidelines (FPL)?
你的收入是否低於300%聯邦貧窮線？
Do you Receive Social Security? (你是否有社會安全養老金？)
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Do you receive SSI? (你是否有生活補助金?)
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Do you receive Private Pension? (你是否有私人退休金？)
Medicare Status (聯邦醫療保險:)
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Do you receive Medi-Cal? (你是否持有加州醫療卡？)
CONTACTS (聯絡)
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Type of Contact (聯絡類型)
Last Name
姓氏
First Name
名字
Middle Name
中間名字
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Relationship (關係)
Address Type
地址類型
County
縣市
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Phone 1: (電話 (1))
Phone 2: (電話 (2))
Email Address (電郵地址)
Contact Notes (注備)
NUTRITION RISK SCREENING (為您的營養健康狀況評分)
Nutritional Risk Screening Questions (營養不良症測試問題)
Yes (是)
No (否)
Decline to state (refuse to answer) (拒絕回答)
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A. I have an illness or condition that made me change the kind and/or amount of food I eat.
我有疾病或其他原因改變了我的飲食習慣
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B. I eat fewer than 2 meals per day.
我每天吃少於兩餐
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C. I eat few fruits or vegetables or milk products
我每天很少吃* 水果, 蔬菜, 牛奶,奶製品的食物
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D. I have 3 or more drinks of beer, liquor or wine almost every day
我幾乎每天都喝三杯以上的啤酒或酒
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E. I have tooth or mouth problems that make it hard for me to eat.
我有牙齒或口腔的問題令我的進食困難
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F. I don’t always have enough money to buy the food I need.
我不是總有足夠的錢去買我所需要的食物
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G. I eat alone most of the time
我經常一個人進餐
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H. I take 3 or more different prescribed or over-the-counter drugs a day.
我每天吃三種以上處方藥或是成藥
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I. Without wanting to, I have lost or gained 10 pounds in the last 6 months.
我的體重在過去的六個月里非刻意增加或減少了10磅
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J. I am not always physically able to shop, cook and/or feed myself.
我不是總有能力去購物、煮飯或者自己進食
FOOD SECURITY AND FOOD PROGRAM UTILIZATION (食物安全和食物計劃使用)
Please read the statements below and check the box appropriate for you/your household.
請閱讀以下句子，選擇最適合關於您／家庭成員的答案。
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1. “We worried whether our food would run out before we got money to buy more.” Was that often true, sometimes true, or never true for your household in the last 12 months:
在過去12個月裡， “我們擔心在有錢去買更多食物之前，所有的食物已經吃完了。”
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2. “The food that we bought just didn’t last and we didn’t have money to get more.” Was that often true, sometimes true, or never true for your household in the last 12 months:
在過去12個月裡，“我們沒有足夠的食物和沒有足夠錢去買更多的食物。”
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3. In the last 12 months, have you or anyone in your household received food from a food program like a food pantry, free dining room, shelter meal, senior congregate meals, school meals, CalFresh, or WIC?
在過去12個月裡，“我們沒有足夠的食物和沒有足夠錢去買更多的食物。”