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STEP 1: Apply For Meals
About You
Personal information needed about you or the senior that you are completing this application for.
Name
*
First Name
Last Name
Gender
*
select one
Male
Female
Other
Are you a
Veteran
Spouse of Veteran
Address
*
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Apartment Complex Name
If applicable
Your Phone #
*
xxx-xxx-xxxx
Marital Status
*
select one
Single
Married
Divorced
Separated
Widowed
Date of Birth
*
(mm/dd/yyyy)
Housing Status
*
Own
Rent
Household Status
*
select one
Lives Alone
With Spouse
With Relatives
With Non-Relatives
With Minor Children
Other
# in Household
*
select one
1
2
3
4
5
6
7
8
9
Total Household Income
Numbers only, no ($) or (.) please
Insurance
*
Medicaid
Medicare
Other
In Case of Emergency
Emergency Contact
*
First Name
Last Name
Phone
*
Emergency Contact Phone
Relationship to You
*
Relative, friend, neighbor, etc.
Health
Health History
*
Heart complications, recent surgeries, blindness, deafness, blood pressure, etc.
Height
*
Weight
*
Social Isolation Score
*
How many people do you interact with per day? (Phone calls included)
Less than 2
3-5
5+
Assistance with ADL's
Notes
Meal Details
Delivery Days
What days would you like meals delivered?
Monday
Tuesday
Wednesday
Thursday
Friday
Weekend (frozen)
# of Cats & Dogs
Ex: 1 dog, 2 cats (cat or dog food only available.)
Pet Food Preference
Wet food
Dry food
Drink Preference
Milk
None
Food Allergies
Any Notes or Comments to Include?
Contact Information
Person to be Contacted About Application
*
First Name
Last Name
Contact Phone
*
Relationship to Client
*
Contact Email
Verify Email
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Name of Person Completing Form
*
First Name
Last Name
Contact Phone
*
Relationship to Client
*