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Go and Dine Registration Form

Hello! Thank you for your interest in the Go N Dine program. We are instituting an online registration process for the program. This will help ensure that we are receiving credit for all the participants we serve, thus sustaining the program. This registration form does not need to be completed if you are already registered with the Stay Fit Dining Program, University Express, or Club 99, as your key tag will work for any Senior Services program that uses a scanner. Once you have completed this webform, you can expect to receive a key tag in the mail. We appreciate your understanding and support as we continue to improve our program and ensure its longevity! Please call 716-858-7639 with any questions about Go N Dine.

Are you completing this form for yourself or someone else?
Are you interested in receiving emails about Erie County Department of Senior Services programs?
Are you a Veteran?
Are you Frail/Disabled?
Living Status
Marital Status
Race
Ethnicity

I hereby consent to my personal information contained in the online registration form being saved in the Client Data System maintained by the New York State Office for the Aging and used by the local Office for the Aging. I understand that my information will not be shared with other agencies without my permission.  I understand that the information on this form may be sent to the State and Federal Government, and is used to improve the services offered and better meet my needs.

By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.