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    NOTE: You will not be able to use this form with the Internet Explorer web browser. If you are using Internet Explorer, please upgrade to Edge, or use a different browser such as Chrome, Firefix or Safari.

    To Qualify for the HOME Program, you must be at least 60 years of age and live within our service area.

    Let's get started by verifying your age.

    YesNo

    Our HOME Program services are available to people age 60 or over. Unfortunately we can not offer you services at this time due to this age requirement.

    To find out information about other programs and services, please call the Senior Linkage Line at 800-333-2433 or visit them online at minnesotahelp.info
    If you have a disability and need help, consider contacting the Disability Hub at 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.

    HennepinSherburneWright

    Our HOME Program services are generally availalbe to residents of Hennepin, Sherburne and Wright Counties. If your City is not listed below, we unfortunately can not offer you services at this time.

    To find out information about other programs and services, please call the Senior Linkage Line at 800-333-2433 or online at minnesotahelp.info

    Great! You live in our service area. Now let's get your basic information.

    You may qualify for financial assistance through Title III.
    Please follow these instructions to complete and return this additional required form from the State of MN.

    1. DOWNLOAD & COMPLETE the form using the free Adobe Reader Software, or print and scan the completed form.
    2. SAVE THE COMPLETED FORM to your computer.
    3. Use the Select Files button, and select the form you just completed and saved.
    4. Click the Upload Files button to securely send the form to our staff and complete this part of the application.

    Please do not return this form by email if you can not upload it.
    Alternately, you can download the form and mail it back to our office at:

    Senior Community Services
    10201 Wayzata Blvd, #335
    Minnetonka, MN 55305

    DOWNLOAD THE INTERACTIVE SUPPORTIVE SERVICES PROGRAM REGISTRATION FORM

    Upload files
     

    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 finished your online application.

    Now that you've uploaded your Program Registration form (or chose to mail it or be contacted), please continue to complete your online registration for our HOME Program!

    NOTE: Must be 60 or older to be eligible for services.

    Non-HispanicHispanic or Latino

    Type of phone you use

    Your main phone number

    Type of phone

    Alternate phone number

    How did you hear about our HOME Program?

    Just your street address, you've already entered your City and we know you live in MN.

    5-digit zip

    Please let us know your housing situation.

    HousekeepingMinor RepairsPaintingHome Safety checksSeasonal Outdoor ServicesTechnology Support

    Please check ALL that apply to you.

    Veteran and Disability Status

    YesNo

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

    YesNo

    This information helps us serve you better.

    Emergency Contact Information

    Optional

    Required

    YOU MUST SUPPLY EMERGENCY CONTACT INFORMATION TO CONTINUE THIS FORM

    OK, now please let us know your living situation and monthly income.

    I live aloneI live with my spouseI live with others

    Please let us know your monthly income so we can establish your eligibility for subsidies & rates for services.

    If you are married or live in a dual-income household, please let us know that persons' monthly income so we can establish your eligibility for subsidies & rates for services.

    Please include all routine monthly income in your calculations. Income sources include Social Security, Pensions, Annuities, PERA, IRA, Retirement Distributions or Withdrawals, Interest Income, Dividends, Estate or Trust, Disability, Public Assistance, Rental Income, Home Equity Funds, Salaries, Self-Employment Income, and all other income sources that are not a voluntary withdrawal of funds.

    Information for your Spouse

    Non-HispanicHispanic or Latino

    Type of phone you use

    Your main phone number

    Type of phone

    Alternate phone number

    YesNo

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

    YesNo

    This information helps us serve you better.

    Other Household Occupant Information

    Non-HispanicHispanic or Latino

    Type of phone you use

    Your main phone number

    Type of phone

    Alternate phone number

    YesNo

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

    YesNo

    This information helps us serve you better.

    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.

    YesNo

    Download and View the Participant Bill of Rights

    YesNo

    Download and View the Non-Discrimination Agreement Document

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

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

    Contact Us

    10201 Wayzata Blvd.
    Suite 335
    Minnetonka, MN 55305
    (952) 541-1019
    (952) 541-0841
    reimagineaging@seniorcommunity.org

    Sign up forms

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