By checking this box I acknowledge that I have received a copy of the Notice of Privacy Practices from St. Joseph County Commission on Aging. I also acknowledge that I have been given the opportunity to discuss these practices and request additional restrictions on the use and disclosure of my Protected Information.

I understand that any pictures taken of me can be used in any St. Joseph County Commission on Aging publications. I will provide a written statement if I wish for my photographs to be excluded.

I understand that the safe handling of any food taken from a senior center or nutrition site becomes my responsibility. This includes the second cold meal or any leftover food from my plate that I decide to take home and I have received information on safe food handling.