202 Medical Heights Dr.
Frankfort, KY 40601
Phone: 502-223-5794
Fax: 502-227-8019
www.frankfortkyseniors.org
“Keeping it young and keeping it fun.”
Welcome to the Frankfort Senior Activity Center. Our federal grant requires that we collect the following information. We
apologize that it might be sensitive information. All information will be held in strictest confidence.
MEMBERSHIP APPLICATION
DATE
NAME
ADDRESS
CITY
STATE & ZIP
EMAIL ADDRESS
HOME PHONE
CELL PHONE
LIVE IN TOWN
LIVE IN COUNTY
Mailing address is the same as residential
Yes
No (If no, please finish this section.)
MAILING ADDRESS
I would like The Grapevine Newsletter mailed to my home.
or at the Center.
GENDER:
Male
MARITAL STATUS:
Single
ETHNICITY:
Non-minority
DATE OF BIRTH (required)
I prefer to get The Grapevine from the website
Female
Married
Divorced
Hispanic
African-American
Bi-racial
Asian/Pacific
VOLUNTEERING
Are you interested in volunteering at the Senior Activity Center?
Yes
No
If yes, what positions would be of interest to you?
Office work
Offer programs, presentations, exercise
Shops
Receptionist
Organize Donations
Newsletter
Craft Center
Other
INCOME LEVEL PER HOUSEHOLD (check the appropriate box)
1 person less than $10,400 per year?
3 persons less than $17,600 per year
2 persons less than $14,000 per year?
4 persons less than $21,200 per year
HOUSEHOLD SITUATION:
Lives alone
With spouse
With children
With relatives
Not reported
PRIMARY CARE PHYSICIAN
PHONE
EMERGENCY CONTACTS (Required; please list 3)
NAME
RELATIONSHIP
PHONE
YES/NO QUESTIONS
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
HIGH NUTRITIONAL RISK
YES (over 6 points)
NO
Nutritional Risk List:
Abused/Neglected/Exploited
None
2 I have an illness or condition that made a change in the
Disabled
amount and/or kind of food I eat.
Female Head of Household
3 I eat fewer than 2 meals per day.
2 I eat few fruits or vegetables or milk products.
Frail
2 I have 3 or more drinks of beer/alcohol every day.
Homebound
2 I have tooth or mouth problems that make it hard to eat.
4 I don’t always have enough money to buy the food I need.
Medicare Eligible
1 I eat alone most of the time.
Receiving Social Security
1 I take over 3 different prescribed or over the counter meds
daily.
Veteran
2 Without wanting to, I have lost/gained 10 lbs. in the last 6
Veteran Dependent
months.
2 I am not always physically able to shop, cook, and/or feed
Medicaid Recipient
myself.
TOTAL POINTS _______
ADLs
Can Do
with no
assistance
With
assistance
(What
type?)
Unable
to do
I ADLs
Feed self
Meal
preparation
Light
housework
Dusting/dishes
Heavy
housework
Pay bills
Use telephone
Medication
Laundry
Transportation
TOTAL
Transfer
Toileting
Bathing/Grooming
Dressing
Walking
TOTAL
2
Can Do
with no
assistance
With
assistance
(What
type?)
Unable
to do
202 Medical Heights Drive
Phone: (502) 223-5794
Frankfort, KY 40601
Fax: (502) 227-8019
Franklin Co. Council on Aging, Inc.
General Administration
Anti-Bullying Policy:
Franklin Co. Council on Aging, Inc. is committed to maintaining a safe and civil work and service
environment, free from Harassment, Intimidation or Bullying. In keeping with this commitment,
FCCOA will not tolerate harassing or bullying conduct that affects tangible job benefits, that
interferes with an individual’s work performance, or that creates an intimidating, hostile or
offensive environment by anyone, including any superior, co-worker, vendor, client, or citizen.
Definition:
Harassment, intimidation, or bullying means any intentional written, verbal, or physical act, when act:
 Physically harms a person or damages the person’s property;
 Has the effect of substantially interfering with a person’s ability to obtain services or perform their
job duties;
 Is severe, persistent, or pervasive that it creates an intimidating or threatening environment; or
 Has the effect of substantially disrupting the orderly operation of the facility.
Harassment, intimidation or bullying can take many forms including: slurs, rumors, jokes, innuendo’s,
demeaning comments, cartoons, pranks, gestures, physical attacks, threats, or other written, oral or
physical actions.
“Intentional acts” refers to the individual’s choice to engage in the act rather than the ultimate impact of
the action(s).
This policy is not intended to prohibit expression of religious, philosophical, or political views,
provided that the expression does not substantially disrupt the environment. Many behaviors
that do not rise to the level of harassment, intimidation, or bullying may still be prohibited by
other agency policies.
Procedure:
1. Expectation for behavior for members, staff, and volunteers.
3
Staff, volunteers, members and family/caregivers shall treat one another with mutual respect. None of
the parties shall subject another to harassment, intimidation or bullying.
2. Behaviors, activities and actions that are prohibited.
Bullying may be intentional or unintentional. However, it must be noted that when an allegation
of bullying is made, the intention of the alleged bully is irrelevant, and will not be given
consideration when meting out discipline. As in sexual harassment, it is the effect of the
behavior on the individual that is important.
Examples of bullying:
 Verbal bullying: Slandering, ridiculing or maligning a person or his or her family;
persistent name calling that is hurtful, insulting or humiliating; using a person as butt
of jokes; abusive and offensive remarks.



Physical bullying: Pushing, shoving, kicking, poking, tripping, assault or threat of
physical assault, damage to a person’s work area or property.
Gesture bullying: Nonverbal threatening gestures; glances that can convey
threatening messages.
Exclusion: Socially or physically excluding or disregarding a person in work-related
activities.
3. Methods for enforcement:
A. FCCOA




Ensure that all employees are aware of the Franklin Co. Council on Aging, Inc. antibullying policy and procedures
Ensure that any incident of bullying is dealt with regardless of whether a complaint of
bullying has been received
Provide leadership and role-modeling in appropriate professional behavior
Respond promptly, sensitively and confidentially to all situations where bullying
behavior is observed or alleged to have occurred
B. Employees



Will be familiar with and behave according to the FCCOA policy
Report incidents of bullying to your supervisor, or Executive Director as appropriate
Where appropriate, speak to the alleged bully(ies) to object to the behavior
D. Members
Staff, volunteers, members and family/caregivers shall treat one another with mutual respect. None of
the parties shall subject another to harassment, intimidation or bullying.
FCCOA may, upon due notice, suspend the membership of an otherwise eligible member. Such
suspension may remain in effect until the FCCOA determines that the danger has been abated or
eliminated.
Members are not to be suspended until the Executive Director has determined that the
membership policies cannot be met due to the behavior of the member or family. Membership
4
may be suspended if the Executive Director or Board of Directors deems that
staff/volunteers/other members will be at imminent risk or danger.
In situations of suspension as described above, a written report that documents the grounds
requiring suspension, attempts to resolve the situation, and written notice that the member may
file a grievance shall be forwarded to the FCCOA Board of Directors.
When conflicts or disagreements occur involving participants regarding mutual respect, the
following steps shall be followed:
 A verbal warning to the member for the first conflict;
 A written warning for a second conflict;
 Suspension;
 In situations of suspension as described above, a written report which documents the
grounds requiring suspension, attempts to resolve the situation and written notice that
the member may file a grievance which shall be forwarded to the FCCOA Board of
Directors; and
 Detailed written records shall be maintained by FCCOA.
E. Enforcement
Inappropriate behavior may lead to termination/non-renewal of membership, exclusion from premises or
the imposition of other appropriate sanctions as may be deemed appropriate in accordance with relevant
procedures.
4. COMMUNICATION OF THE POLICY
FCCOA is committed to taking positive measures to educate all staff, volunteers and members,
in awareness of bullying and harassment and the effects of this type of behavior. Our
commitment is to bring the policy to the attention of management, staff, volunteers and
members.
.
This will be achieved by the following:
 Induction training;
 Circulation of policies;
 Bullying and harassment awareness initiatives;
 Training managers/supervisors to deal with bullying & harassment issues.
 Increasing awareness at facility where services are provided.
 Agreements with Members
5. Reporting Procedures of incidents by staff and members.
Should either party feel that an offense has occurred; recourse shall be sought through the mediation,
grievance, or complaint procedures established by the FCCOA.


Any employee who feels he or she has been victimized by bullying is encouraged to
report the matter to his or her supervisor, the executive director or with the board of
directors.
Members who feel they have been victimized may contact the executive director or
board of directors.
5


Where appropriate, an investigation will be undertaken and disciplinary measures will
be taken as necessary.
All incidents shall be documented.
6. Discussions regarding challenges and solutions.
Given the often personal nature of bullying or harassment, the recipient may need to discuss his/her
concerns in total confidence with someone else, in a safe environment. The executive director or
assistant director can be contacted directly at any stage for counselling, support and guidance
throughout the process.
7. Methods to assist those being bullied.
 Emphasize the importance of standing up for their rights.
 Provide assistance for managing anger.
 Establish boundaries.
 Ensure the individual knows who to report future incidents.
 Encourage continued participation in program to ensure they are connected with the community.
8. Methods to address the bully including
 Discuss issues and explain policy and procedure requirements.
 Find ways to assist the individual to remain involved and establish friendships.
 Refer for counseling when appropriate.
 Referral to law enforcement when appropriate.
9. Grievance/ Complaint Procedure:
Employees or members will follow the procedures of the Franklin Co. Council on Aging, Inc., or the
procedures of their governing body.
Compliance:
Franklin Co. Council on Aging, Inc. shall designate an employee or officer to coordinate its efforts to
comply with the provisions of the above referenced Acts. Compliance shall be monitored through
evaluations, monitoring and satisfaction surveys.
FCCOA administration – Anti-Bullying
Adopted 1/13/2015
6
BLUEGRASS AREA DEVELOPMENT DISTRICT
CODE OF
CONDUCT &
ETHICS
7
Table of Contents
I.
INTRODUCTION .............................................................................................................3
A)
RESPECT FOR PEOPLE’S RIGHTS AND DIGNITY ...................................................3
II.
PARTICIPANT CODE OF CONDUCT .............................................................................3
A)
PHILOSOPHY...............................................................................................................3
B)
RIGHTS & RESPONSIBILITIES OF PARTICIPANTS .................................................. 3
C)
PARTICIPANTS AT CENTER OR CENTER-RELATED ACTIVITIES
ARE PROHIBITED FROM .........................................................................................4
D)
SEXUAL HARASSMENT ..............................................................................................4
E)
HAZING ........................................................................................................................5
F)
TOBACCO USE ............................................................................................................5
G)
DRUG & ALCOHOL USE..............................................................................................5
H)
WEAPONS....................................................................................................................5
I)
ASSAULTS ...................................................................................................................6
III.IMPLEMENTATION OF THE CODE ......................................................................................6
A)
RESPONSIBILITY & AUTHORITY FOR ENFORCEMENT ..........................................6
B)
RESPONSIBILITY OF STAFF FOR MAINTAINING THE CODE ..................................6
C)
FACTORS TO CONSIDER ASSESSING EACH CASE ................................................6
D)
JURISDICTION .............................................................................................................6
E)
RIGHT OF APPEAL ......................................................................................................7
8
INTRODUCTION
RESPECT FOR PEOPLE’S RIGHTS AND DIGNITY
All participants who attend the Senior Citizens Center are expected to respect the dignity
and worth of all people, and the rights of individuals to privacy, confidentiality, and selfdetermination. Participants should be aware of and respect cultural, individual, and role
differences, including those based on age, gender, gender identity, race, ethnicity, culture,
national origin, religion, sexual orientation, disability, language, and socioeconomic status.
This Code of Conduct & Ethics applies to the Senior Citizens Centers’ and its participants.
Staff and community members developed it. It is based on the premise that every senior
center should have discipline. It is our belief that when unacceptable behavior patterns do
occur, all concerned understand the consequences. When discord does arise, adherence to
this Code will assure that all parties are treated with courtesy, respect, fairness, yet with a
firmness that will direct participants to conduct themselves in an acceptable manner.
II)
PARTICIPANT CODE OF CONDUCT
PHILOSOPHY
The mission of the Center is to create a home-like atmosphere that gives each
participant a welcome feeling. This can only be accomplished when the Center is free
from disruptions that could interfere with day-to-day activities. The purpose of the
Code is the expectations for responsible participant behavior, and the consequences of
irresponsible and disruptive behavior. It is expected that participants will be
responsible for their own self-discipline in accordance with stated expectations.
However, when a violation of the Code of Conduct & Ethics does occur, discipline will
be administered in order to correct the disruptive behavior and to protect all in a safe
environment.
RIGHTS & RESPONSIBILITIES OF PARTICIPANTS
1) All participants are entitled to the basic rights of citizenships recognized and protected by law
for persons of their age and maturity. The Center will foster a climate of mutual respect for
the rights of others. Participants are expected to respect the rights and privileges of other
participants and staff. The Center’s Code of Conduct & Ethics is established to achieve and
maintain order in the Center. Participants who violate the rights of others or who violate the
Center rules will be subject to disciplinary measures designed to correct misconduct and to
promote adherence by all participants their responsibilities as citizens in the community.
2) Participants responsibilities for achieving a positive environment at Center-related activities
include:
(a) Actively participating in Senior Citizen Center-related activities
(b) Respectful toward others
9
(c) Appropriate dress/attire while at the center or during off-site center activities
(d) Be clean and free from body odor
(e) Behaving in a responsible manner
(f) Observing Centers safety rules
(g) Exhibiting responsible conduct at the Center, and on all Center sponsored trips and
activities
(h) Report any abusive behavior or violations of the Code of Conduct & Ethics to proper staff
members
(i) Refraining from violations of this Code of Conduct & Ethics
PARTICIPANTS AT CENTER OR CENTER-RELATED ACTIVITIES ARE PROHIBITED FROM:
1) Throwing objects that can cause bodily injury or damage property
2) Directing profanity, vulgar language, or obscene gestures toward participants or staff
3) Insubordination, such as not following Center policies, rules, and regulations
4) Committing arsonist acts at or toward the Center
5) Engaging in any conduct constituting felony criminal mischief as defined by law including
robbery or theft at Center or from Center participants or staff or damaging or vandalizing
property owned by the Center, other participants, or staff
6) Not observing this Code of Conduct & Ethics and Senior Citizen Center rules while being
transported on Senior Citizen Center transportation
7) Fighting, committing physical abuse, or threatening physical abuse
8) Committing extortion, coercion, or blackmail, which is obtaining money or other objects of
value from an unwilling participant or forcing a participant to act through the use of force or
threat of force
9) Engaging in verbal abuse, name-calling, racial slurs, or derogatory statements that may disrupt a
Center program or incite violence
10) Engaging in inappropriate physical or sexual contact disruptive to the Center environment
or disturbing to other participants
11) Committing indecent exposure, mooning, etc.
12) Speaking, writing, or suggesting a violent or illegal action toward some Center participant
or staff
13) No soliciting, canvassing or peddling upon Senior Center premises for the purpose
other than donations that support senior center activities and programs.
SEXUAL HARASSMENT
The Center believes that every participant has the right to attend the Center and all Centerrelated activities free from all forms of discrimination on the basis of sex, including sexual
harassment. The Center considers sexual harassment of participants to be serious and will
handle according to the nature of the offense.
All participants are prohibited from engaging in offensive verbal or physical conduct of a
sexual nature directed toward another participant or Center staff member. This
prohibition applies whether the conduct is by word, gesture, or any intimidating sexual
conduct. If the resolution of sexual harassment is not handled satisfactorily by the staff for
the participant, they can call a meeting with the Senior Citizens Program.
10
HAZING
Hazing is any willful act done by a participant for the purpose of subjecting the other to
indignity, intimidation, physical abuse or threats of abuse, social or other ostracism, shame
or disgrace.
No participant shall engage in any form of hazing, nor shall any participant encourage or
assist any other person in hazing.
TOBACCO USE
State law prohibits the use of tobacco or tobacco products in the Center. Senior Citizen
Center prohibits the use of tobacco or tobacco products while being transported on Senior
Citizen Center transportation.
DRUG & ALCOHOL USE
No participant shall be under the influence, possess, use, or transmit any of the following
substances at the Center or at Center-related activities, functions, on Center transportation,
or events:
1) Alcohol or any alcoholic beverage
2) Any controlled substance or dangerous drug as defined by law such as marijuana, any
narcotic drug, hallucinogen, amphetamine, or barbiturate
3) Any amusable glue, aerosol paint, or any chemical substance for inhalation
4) Any other intoxicant, or mood-changing, mind-altering or behavior-altering drug
prohibited by the FDA
To “use” means a participant has smoked, ingested, injected, inhaled, drunk, or otherwise
taken internally a prohibited substance enough that it is detectable by the participant’s
physical appearance, actions, breath, or speech. “Under the Influence” means the
participant faculties are noticeably impaired, but the participant need not be legally
intoxicated. The transmission or sale of any of the listed substances is prohibited under
this Code.
WEAPONS
A participant shall not be in possession of a weapon at the Center or at any Center-related
activity, unless he or she has written authorization. Weapons include:
Firearms of any kind
Razors
Large Fireworks
Clubs or nightsticks
Chains
Brass Knuckles
Pellet guns, BB guns, or slingshots
Switchblades or Knives (excluding pocket knife)
Any object used to threaten or inflict harm to another person
ASSAULTS
Participants are prohibited from assaulting other participants or a staff person of the
Center while participating in any Center-related activity. An assault is defined as:
11
Intentionally, knowingly, or recklessly causing bodily injury to another
Intentionally or knowingly threatening another with imminent bodily injury
Intentionally or knowingly abusing physical contact with another when the participant
knows that the other will regard the contact as offensive or provocative.
IMPLEMENTATION OF THE CODE
RESPONSIBILITY & AUTHORITY FOR ENFORCEMENT
The staff shall have the responsibility of implementing the Code.
A participant can be removed from the Center for a violation or issue of the Code if the staff
believes that such action is necessary, or to protect a person or property from imminent harm.
RESPONSIBILITY OF STAFF FOR MAINTAINING THE CODE
Assure a safe and orderly environment for participants.
Enforce the Center’s Code of Conduct & Ethics.
Report any conduct issue or problem to the senior citizens program.
Maintain an orderly atmosphere at the Center.
Maintain confidentiality for participants.
FACTORS TO CONSIDER ASSESSING EACH CASE
The seriousness of the issue or problem.
The participant’s attitude.
The frequency of the misconduct.
The effect of the misconduct on the Centers’ environment
JURISDICTION
The Center has jurisdiction over its participants during the regular workday and while
going to and from the Center on the Center transportation. The Centers’ jurisdiction
includes any activity during the workday at the Center or in attendance at any Center
related activity, regardless of time or location. Center related misconduct, including
retaliation against an employee, regardless of time or location if such conduct has a
direct effect on maintaining order and discipline or on protecting the safety of
participants and staff at the Center.
E) RIGHT OF APPEAL
Any participant has the right to appeal removal from the Senior Citizens Center or Center
related activities. The request for appeal must be submitted in writing to the Board of
Directors of the local Center. If the participant is not satisfied with the Board of Directors
decision they may submit in writing to the Bluegrass Area Development District Area
Agency on Aging and Independent Living at 699 Perimeter Dr., Lexington, KY 40517,
must be addressed to the attention of Celeste Collins, Director of Aging.
12
RELEASE AND WAIVER OF LIABILITY OF EXERCISE ROOM EQUIPMENT AND
USAGE AND EXERCISE PROGRAM PARTICIPATION
Please read this form carefully.
I do hereby assume the full risk of any injuries and all costs, damages, and losses that I may sustain as a result
of participating in any and all activities connected with or associated with the exercise room.
I assume all risks associated with my participation in the exercise room and hereby release and hold harmless
the Frankfort Senior Activity Center the sponsors of and suppliers to the exercise programs and their
respective exercise programs and their respective programs and their respective directors, officers,
employees, agents, successors and assigns, from and against any and all claims, damages, liabilities and
expenses arising from my participation in any of the exercise programs or equipment.
By signing this form, I understand that I will be waiving and releasing all claims arising out of the use of the
exercise equipment and any participation in the exercise programs.
Signature
Date
GENERAL PHOTOGRAPHY RELEASE
Please read this form carefully.
I hereby authorize Frankfort Senior Activity Center to publish photographs taken of me, and my name and
likeness, in any and all of its publications, including but not limited to all Frankfort Senior Activity Center’s
printed and digital publications, websites, and social media sites and news media. I understand and agree that
any photograph using my likeness will become property of Frankfort Senior Activity Center and will not be
returned. I acknowledge that since my participation with the Frankfort Senior Activity Center is voluntary, I will
receive no financial compensation.
I hereby authorize Frankfort Senior Activity Center to edit, alter, copy, exhibit, publish or distribute any
photographs of me for purposes of publicizing Frankfort Senior Activity Center’s programs or for any other
related, lawful purpose. I waive the right to inspect or approve the finished product, including written or
electronic copy in which my likeness appears. I waive any right to royalties or other compensation arising or
related to the use of the photograph.
I hereby hold harmless and release and forever discharge Frankfort Senior Activity Center from all claims,
demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other
persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.
Yes
No
Signature
Date
13
202 Medical Heights Drive
Frankfort, KY 40601
Phone: 502-223-5794
Fax: 502-227-8019
“Enhancing Senior Living”
Board of
Directors
Judy Campbell
Chair
Chuck Fletcher
Vice Chair
I have received, read, and understand the Code of Conduct and Ethics along with
the Anti-bullying policy. I agree to adhere to the conditions listed within these
documents in order to participate in any events or activities provided by
Kaye Triplett
Secretary
Tom Current
Treasurer
Chuck Hardin
X
Paricipant Signature and Date
Tammy Payton
Dr. Brett Scott
Dr. Jan Weisberg
Curtis Hopkins
X
Senior Center Staff Signature and Date
Rosemary Center
James Badgett
Wayne Morris
Emeritus
Members
of the Board
Bert Sisk
Chris Richards
14