HOME Program Online Application - Senior Community Services

First Name

Middle Initial

Last Name

Date of Birth

GenderMaleFemaleOther

Race

Hispanic Ethnicity?Non-HispanicHispanic or Latino

Main Phone Type

Type of phone you use

Number

Your main phone number

Alt Phone Type

Type of phone

Number

Alternate phone number

Email Address

Are you a veteran of the U.S. Military?YesNo

We may be able to give you more information about VA benefits if you need it.

Do you have a physical disability or mobility challenge
we should be aware of?YesNo

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Please describe your disability or mobility challenge:

This information helps us serve you better.

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Use of Information Statement

I understand that the information I am providing on this form is for registration purposes. I certify that the information provided on this form is accurate and complete. I authorize Senior Community Services to verify this information, if necessary, and to provide this form to governmental entities as a condition of funding they provided to this agency. 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.

I have read and agree to the PARTICIPANT BILL OF RIGHTS*YesNo

Download and view the Participant Bill of Rights

I have read and agree to the NON-DISCRIMINATION AGREEMENT*YesNo

Download and view the Non-Discrimination Agreement

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HOME Program Applicant Signature*

By typing your full legal name, you are providing a digital signature for this application.

Date*

Send Your HOME Program Application

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To qualify for the HOME Program, including Technology Services, you must be at least 60 years old and live within our service area.

Are you, or the person you're enrolling, age 60 or older?*

YesNo

Unfortunately, you are not eligible for HOME Progam services at this time.

If you have a disability and need help, consider contacting the Disability Hub at 1-866-333-2466 or visit them online at disabilityhubmn.org.

Great! Now let's check to see if your location is eligible for HOME Program Services

Which county do you live in?*

HennepinSherburneWright

The HOME Program service area for your selected county includes the cities listed below. If your city is not listed, we cannot provide services to you currently. To find services available in your city, please call the Senior Linkage Line at 1-800-333-2433 or minnesotahelp.info.

Great! You live in the service area. Now let's get additional information.

To see if you may qualify for financial assistance through Title III, please follow these instructions to complete and return the Supportive Services Program Registration form from the State of Minnesota.

Were you able to upload the Program Registration form?*

YesNoI will send my Program Registration form by standard mailPlease contact me to complete the Program Registration form

PLEASE CONTINUE YOUR APPLICATION REGARDLESS OF THE FILE UPLOAD RESULT

Someone from our staff will contact you to complete this form once you've submitted your online application.

Please continue completing your online registration for the HOME Program:

Veteran and Disability Status

Emergency Contact Information

YOU MUST SUPPLY EMERGENCY CONTACT INFORMATION TO CONTINUE THIS FORM

Please share your living situation and monthly income.

Information for your spouse

Other Household Occupant Information

Use of Information Statement

Most of our staff speak English, and we coordinate with interpreting services and culturally-specific community agencies to best serve our clients.

Contact Us

Sign up forms

Did you know?

Embracing the Caregiver Journey: Finding Balance and Compassion

SCS Earns National Recognition for Technology Services Program for Older Adults

Empowering Aging: The Vital Role of Community Nonprofits

INSTAGRAM