Membership Application Non-Profit - PDF Templates

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Membership Application

General Information

Date

Friday, January 17, 2025

Client ID Number

092564

Contact Name

Tina D Barkus

Other Phone

(555) 555-5555

Preferred Phone

(555) 555-5555

Date of Birth

Wednesday, September 9, 1959

tinabarkus@gmail.com

Veteran

Monthly Income

2500

Housing

Mailing Address

925 Brockhurst

Oakland, CA, 94565

United States

Do you have someone we can contact in an emergency situation?

YES

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Emergency Contact

Emergency contact First Name

Brittany

Emergency contact Last Name

Hale

Emergency contact Phone

(555) 555-5555

Emergency Contact Address

25 Railroad

Pittsburg, California, 94565

United States

Nutrition

I eat fewer than 2 meals each day.

Yes

I have an illness or condition that made me change my diet.

Yes

I eat few fruits and vegetables.

Yes

I have 3 or more drinks of beer, liquor or wine almost every day.

Yes

I have tooth or mouth problems that make it hard for me to eat.

I don’t always have enough money to buy the food I need.

Yes

I eat alone most of the time.

Yes

I take 3 or more different prescribed or over-the-counter drugs a day.

Yes

Without wanting to, I have lost or gained 10 pounds in the last 6 months.

Yes

I am not always physically able to shop, cook and/or feed myself.

Are you interested in quitting or reducing your tobacco use?

True

Do you have emotional support?

Do you feel safe w

here you live?

Yes

ADL

Eating and Bathing

1 / 5

Walking and Dressing

1 / 5

Meal Preparation, Shopping, and Transporation

1 / 5

Medication Managment, Money Management, Use of Telephone, Transportation

1 / 5

Programs of Interest

Breakfast and Lunch Services

Friendly Visting (Wellness Checks)

Hope and Justice (Senior Advocacy)

Tai Chi (Exercise Courses)

Smoking Cessation (Smoking Prevention Courses "Ash Kickers")

Health & Wellness Education

Information & Referrals

Light Case Management

Housing Navigation Case Management (Unhoused Seniors Only)

AOD (Substance Abuse Prevention)

Additional Questions

Signature

Flow Activity History

Actor	Actions	Date
Notification	undefined Step - Reminder Email sent to kwong@stmaryscenter.org	Saturday, January 18, 2025
Kristina Wong kwong@stmaryscenter.org	Waiting for Kristina Wong's action.	Friday, January 17, 2025

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Item - Membership Application Non-Profit Image-1 2

Community Standar

ds Commitment

St. Mary's Center believes in every person's

right to mutual peaceful enjoyment; fosteri

ng an environment that holds ALL in high reg

ard, and genuinely respects differences in c

lass, age, race, culture, gender, and belief

s. We also believe in a person's right to fr

eedom from all forms of violence including t

he effects of poverty and homelessness. We a

re committed through policy, word, and actio

n to create a clean and sober environment th

at is welcoming for all.

It is expected that the full St. Mary's Ce

nter community will practice high standard

s of behavior by:

Always communicating
with respect and dign
ity
Showing support for each other while
practicing self-care and healthy bo
undaries
Demonstrating acceptance, empathy, in
clusivity, non-judgment, and accounta
bility
Using the Grievance Process to work thr
ough challenges with staff and other me
mbers

It is expected that on St. Mary's Center ·p

roperties staff, members, and non-members w

ill NOT:

Engage in verbal harassment including behav
ior that feels threatening to someone else
and does not respond to de-escalation inter
vention
Make physical threats, harassment, o
r physically assault individuals or
property
Use illegal substances or al
cohol on St. Mary's Center g
rounds
Smoke cigarettes or marijuan
a or display smoke paraphern
alia
Steal food or property including
food and materials available for
donations
Sell or purchase ill
egal or prescription
drugs
Sell or purchase services or products,
homemade or otherwise, from staff or me
mbers
Will not borrow money or accept gifts
of extraordinary value from staff or
members
Exhibit behavior that disturbs the peaceful
enjoyment of community activities particul
arly, but not exclusively when under the in
fluence of alcohol, and/or illegal substanc
es including abuse of prescription medicati
on
Bring in weapons or materials that can be
used as weapons, or brandish items as we
apons.
Those engaged in these behaviors will be as
ked to leave SMC immediately, and if approp
riate, a re- unification strategy will be i
nitiated.

I, Tina D Barkus agree to practice to t

he best of my ability the Community Stand

ards outline above.

Item - Signature 3

Signatu

Friday

, January 17,

2025

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Item - Membership Application Non-Profit Image-2 4

Art Work, Story, Photo and Video Media Release Form

St. Mary's Center shares images, stories and creative works by Seniors to increase awareness and educate our community on issues related to the extremely low-income seniors we serve and to promote the work of the agency. We respect each person's privacy regarding presenting personal work to the public.

I, _ Tina D Barkus _ give permission to be photographed and videotaped at events connected with St. Mary's Center and its affiliate. I understand that my image and creative work may be included in reports, publications, grants, news media, exhibits, websites, social media and other paper and Internet venues.

I give permission to St. Mary's Center to use my name as (check one)