Are you filling out this application form on someone's behalf? *

Yes

No

Name of Client *

First Name

Last Name

Client's Date of Birth *

MM

DD

YYYY

Address of Client *

Please write the residence where the food should be delivered.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number *

Please submit best phone to reach the client.

(###)

###

####

Is the above phone number the client's or another individual's (eg. caretaker, family member)?

Client

Other

Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone Number *

(###)

###

####

Emergency Contact Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name of Payee

First Name

Last Name

Billing Address

The billing address will receive receipt for the previous month's meals at the end of each month. It should be the client's address, or that of the individual paying for the meals. Send payment by mail to the Meals on Wheels NEI office, or call to pay by card.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Would the payee like to apply for reduced meal costs?

The Client Coordinator will explain the brief application process during the intake conversation.

Yes

No

Client's Diet *

Our kitchen serves all diabetic- and cardiac-friendly meals. Please indicate any other dietary needs. You may call the Meals on Wheels NEI office at any time to update or modify dietary instructions.

Pureed

Mechanical soft

Pescetarian/Vegetarian

General

Other (describe below)

Delivery Days *

Please note: Sunday meals will be delivered with Saturday meals.

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Beverage *

Please select up to two beverages.

Apple Juice

Milk

Kefir (drinkable yogurt)

Tea Bag (Lipton black tea)

None

Agreement & Disclosure *

By submitting this form, I have reviewed the diet information above and understand that the duty of MEALS ON WHEELS is to prepare and deliver my meals. 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.

I Agree