St. Mary's County Government
Department of Aging & Human Services
Health Fair 2019: The Way to Wellness
Date of Birth:
2 Or More Races
American Indian/Alaskan Native
Hired Caregiver/Assisted Living
Adult with a Disability
Hispanic or Latino
Not Hispanic or Latino
Please indicate if you plan receive a flu shot at the 2019 Health Fair:
MARYLAND DEPARTMENT OF AGING
The information you put on this form will be used to (1) help improve programs for seniors, or (2) find out if you qualify for a program. It may be shared with the Maryland Department of Aging ("MDoA").
The Commissioners of St. Mary's County through the Department of Aging and Human Services and MDoA will not voluntarily share any facts that identify you with anyone except people working for them who need the facts to perform their jobs. Facts that identify you include your name, address, and telephone number.
You may refuse to give some or all of the information asked for. However, if a program is only for people who meet its qualifications (such as age, income, or health condition) and you do not share the facts that show you qualify, then you will not be able to take part in that program. St. Mary's County Department of Aging and Human Services staff can tell you exactly which facts are needed to show you qualify for a program.
You may look at a record that identifies you. You may do this to make sure the facts are right. To look at such a record you must write to St. Mary's County Department of Aging and Human Services, Attention AIM/NAPIS Administrator, P.O. Box 653, Leonardtown, MD 20650 or Maryland Department of Aging and Human Services, Attention AIM/NAPIS Administrator, 301 West Preston Street, Suite 1007, Baltimore, MD 21201.
I have read and understand the above Informed Consent Notice.