Client Application

Name *
Name
Phone *
Phone
Date of Birth *
Date of Birth
Address *
Address
Living Situation
Marital Status
Delivery Days
Diet Requirements *
Select one
Beverage *
If you chose milk...
Billing Address
Billing Address
If different than your delivery address
Emergency Contact *
Emergency Contact
Emergency Contact Phone Number *
Emergency Contact Phone Number
Physician’s Phone Number
Physician’s Phone Number
Additional Information
The following information is for grant writing purposes and is helpful but not required information:
This information is for grant writing purposes and is helpful but not required information.
Are you a veteran?
Are you the spouse of a veteran?
Are you disabled?
Are you also interested in Meals on Wheels’s Friendly Visitor program?
Grocery Shopping/Food Pantry programs?
Agreement & Disclosure *
By submitting this form, I have reviewed the diet information above and understand that the duty of MEALS ON WHEELS is to deliver my food. MEALS ON WHEELS does not prepare the food. I hold MEALS ON WHEELS free of harm from the effects of any incident that may occur in the normal course of business between MEALS ON WHEELS, its volunteers and myself.