PO Box 416 • 30 Wellness Way • Sparta, NC 28675

Welcome to our family!

Section 1:Required for all clients

This short Form of the DAAS-101 Client Registration Form may only be used to register congregate meal and transportation clients. Complete all applicable information below.

  • HCCBG congregate nutrition (180), NSIP-only congregate meals (181), congregate liquid nutritional supplements(182) – complete Sections 1, 2, and 7 only.
  • HCCBG general (250) or medical (033) transportation – complete sections 1 and 7 only.
Leave this field blank
Client Status: Check the appropriate box(es). Enter the date of client status change.
(Complete Section 1 - 2, 4, 5, plus the information that needs to be changed)
Enter reason for making client inactive. Make a client inactive only if the person is thought to be permanently leaving the service system. Indicate the reason for making the client inactive below. If the client is a caregiver receiving FCSP or Project C.A.R.E. services and the reason for making the client inactive relates more to the care recipient's status, check the box for "care recipient."
If Client has NO PHONE put (None):
Enter the clients Self-reported overall functional status here. If the client receives other services in addition to congregate nutrition and transportation, use the DAAS-101 Long Form to register the client and complete section IV to report functional status.
Required only for congregate meals, congregate liquid nutritional supplement, or NSIP-only congregate meals.
SECTION 7: REQUIRED FOR ALL CLIENTS: I, the client, understand that the information contained on this form will be kept confidential unless disclosure is required by court order or for authorized federal, state or local program reporting and monitoring. I understand that any entitlement I may have to Social Security benefits or other federal or state sponsored benefits shall not be affected by the provision of the aforementioned information. My signature authorizes the providing agency to begin the service(s) requested.

Our Mission

The mission of Alleghany County Council on aging (ACOA) is to promote the well being of Alleghany County’s older adults by supporting services and activities which are intended to enhance their dignity, support their involvement in and with our community.

PO Box 416 • 30 Wellness Way • Sparta, NC 28675