Home Care & Repair Application Home Care & Repair Application "*" indicates required fields Step 1 of 5 - Your Information 20% Your InformationName* First Middle Last Birthdate* MM slash DD slash YYYY Gender* Do you identify as LGBTQ?* Yes No Home Address* Street Address Address Line 2 City MNAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code My physical address is the same as my mailing address. Yes Mailing Address* Street Address City MinnesotaAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County* Primary Phone*Work PhoneEmailCommunication Preference:* Phone Call Text Message Email Race (Check all that apply):* American Indian or Alaska Native Asian or Asian American Black or African American Native Hawaiian or Pacific Islander White Ethnicity (Check one):* Hispanic or Latino Non-Hispanic Do you identify as an immigrant / foreign-born US citizen?* Yes No Are you a veteran?* Yes No Emergency Contact* Emergency Contact - Phone*Emergency Contact Relationship:* How did you hear about Home Care & Repair?*Online SearchFamily / FriendNewspaperFlyerWord of MouthSocial MediaOther Insurance & Assistance InformationDo you receive Medical Assistance (MA)?* Yes No Medical Assistance Card*Max. file size: 300 MB.Please upload a photo of the front and back of your card.Do you have Prime West Insurance?* Yes No Insurance Card*Max. file size: 300 MB.Please upload a photo of the front and back of your insurance card.Do you have a Caregiver and/or Case Worker?* Yes No Can WCMCA contact your Caregiver and/or Case Worker?* Yes No Caregiver/Case Worker Name:* Phone*Do you receive additional services through WCMCA?* Yes No Additional Services:* Home Care ServicesI would like to receive Homemaking Services.* Yes No I am interested in the following Homemaking Services:* Kitchen Cleaning - Including dishes Cleaning floors - Sweeping, mopping, vacuuming Dusting Make Bed Laundry Empty trash cans Grocery shopping I would like to receive Maintenance Services* Yes No I am interested in the following Repairs Maintenance Services:* Window, Door, or Flooring Repair Toilet or Faucet Leaks Slow Drains Light switch/outlet cover replacement I am interested in the following Mechanical Maintenance Services:* Change filters (furnace, A/C, drinking water) Clean A/C unit Fan, coil, vent cleaning I am interested in the following Mechanical Maintenance Services:* Clean Gutters Siding, trim, or gutter repair Stair or handrail repair I would like to receive Chore Services* Yes No I am interested in the following Deep Clean/Organize Chore Services:* Window Cleaning - Inside or Out Cleaning Appliances - Stove, Oven, Refrigerator Organizing - Counters, Storage, Garage Packing Items - To put into storage or moving Moving furniture I am interested in the following Fix/Preventative Chore Services:* Fill water softener Changing light bulbs Fixing loose furniture Hanging pictures/shelves I am interested in the following Exterior Chores Chore Services:* Mowing Raking Trimming plants - To prevent rot to house Yard pickup Snow removal - Snow blow/Shovel If there are any services you require that are not listed above, please list them below and we can discuss during your in-home assessment. Household InformationDo you own your home?* Yes No Household Size (Check one):* I live alone I live with others Household Size* Additional Household Members*Please list names of spouse, children, etc. Annual Gross Income* My monthly income is between:* $1,215/month or less $1,216-$1,823/month $1,824-$2,430/month More than $2,430/month Our monthly income is between:* $1,643/month or less $1,644-$2,465/month $2,466-$3,287/month More than $3,827/month Care AssessmentCan you walk around inside without any help?* Yes No Can you bathe or shower without any help?* Yes No Can you sit up or move around in bed without any help?* Yes No Can you use the toilet without any help?* Yes No Can you comb your hair, shave, wash your face, or brush your teeth without any help?* Yes No Can you dress without any help?* Yes No Can you get in and out of bed or chair without any help?* Yes No Can you answer the telephone or make phone calls without any help?* Yes No Can you manage eating without any help?* Yes No Can you do heavy house cleaning, like yard work and laundry, without any help?* Yes No Can you shop for food and other things you need without any help?* Yes No Can you take your medications without any help?* Yes No Can you prepare meals for yourself without any help?* Yes No Can you handle your own money, like keeping track of bills without help?* Yes No Can you do light housekeeping, like dusting or sweeping, without any help?* Yes No Can you use public transportation or drive beyond walking distances without any help?* Yes No I understand that the information I am providing on this form is for registration purposes. The information will be used by the U.S. Health and Human Services Administration for Community Living (ACL), the Minnesota Board on Aging (MBA) and the local Area Agency on Aging to create statistical reports. ACL, MBA, or its assignees may use this information to conduct a study and/or survey of this service. In addition, information provided here, may be used by other service providers to help identify other services from which I may benefit. This information will not be released to anyone other than the above mentioned parties in a way that will identify me as an individual unless I sign a separate consent for that purpose. My signature (written or typed) indicates my agreement for this information to be used as indicated above.Signature*NameThis field is for validation purposes and should be left unchanged. Δ
