Meals on Wheels of Central Maryland

Client Application

* Required Field

Client’s Information

*Last Name:	*First Name:	M.I.:	*Title:

*Address:	Apt. #:

*City:	*State:	*Zip:

*Phone (Home):	Long Distance?

Social Security #:	Sex:	Marital Status:

Race:

Birthdate:

Directions to Client (Please include cross streets):

Is there a pet in the home?
Will the client need help with meals?
Does the client speak English?
Does the client have access to a refrigerator?

How does the client manage on weekends?

Will client have difficulty answering the door?

If yes, specify nature of problem and how volunteer will enter client's home.

Emergency Contacts

(Local Residents who can check on client in an emergency not living in same residence - day time phone numbers required)

Emergency Person 1

Name:

Relationship:

Has a key to the client's home?

Address:

Apt. #:

City:

State:

Zip:

Phone (Home):

Phone (Work):

Phone (Cell):

Emergency Person 2

Name:

Relationship:

Has a key to the client's home?

Address:

Apt. #:

City:

State:

Zip:

Phone (Home):

Phone (Work):

Phone (Cell):

*Does client live alone?

Yes No

If no, specify names and relationships of other person(s) in household:

Name:

Relationship:

Name:

Relationship:

Name:

Relationship:

Why is the above listed person(s) unable to prepare meals for client?

Service Eligibility

(Please comment as to why client is homebound and unable to shop or cook)

*Why does client need service?

How did you hear about Meals on Wheels?

Please specify:

Client’s Physician

Name:

Street:

City:

State:

Zip:

Phone:

Medical Problems

Arthritis		High Blood Pressure
Heart Disease		Lung Disease
Stroke		Diabetes
Seizures		Surgery
Cancer		Confusion
Depression		Amputee
Alzheimers		Alcoholism
Cataract		Parkinson's Disease

Monthly Income Information

(For anyone living with a spouse, include both incomes)

Income	Client	Spouse
Social Security:
SSI:
Pension:
Dividends:
Interest:
Food Stamps:
Other:
Total combined Income:

Expenses	Client
Housing:
G & E:
Phone:
Oil:
Taxes:
Insurance:
Rx:
Medical:
Other Meals:
Total:

Disposable Income:

Person Responsible for fee:

Same as the client?

Name:

Street:

Apt. #:

City:

State:

Zip:

Phone (Home):

Phone (Work):

Phone (Cell):

Contact Person

Who should we contact to discuss fee and service? (Daytime phone number required)

*Name:	*Phone:

Referral Information

Referred by:

Name:

Name of Agency:

Position:

Phone:

Pager:

Website URL: If you can read this, DO NOT fill in this field.

Glasses?
Hearing Aid?
Mobility Assistance?	(cane, walker, wheelchair, etc.)

Meals on Wheels of Central Maryland

Client Application

Client’s Information

Emergency Contacts

Service Eligibility

Client’s Physician

Medical Problems

Monthly Income Information

Referral Information

Submit