Client Application - Meals on Wheels of Central Maryland

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Application for Service

Client Information

First Name *

Last Name *

M.I. *

Gender

Male

Female

Ethnicities*

Address *

City*

Zip Code *

County *

Birthdate *

Social Security # *

Phone (Home) *

Phone (Cell) *

Email *

Language Spoken *

Translator? Please include name and phone number: *

Who should we contact regarding the application? (Please include name and phone number) *

Additional Questions

Special Requests

Kosher Food

No Pork

No Fish

Texture Modified

Days Requested

Monday

Tuesday

Wednesday

Thursday

Friday

Weekend

Is this anticipated to be a temporary need following surgery, etc.?*

Emergency Contacts

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

Emergency Person 1*

Name*

Phone (Home)*

Phone (Work)*

Phone (Cell)*

Email *

Are they local?

Yes

Does this person have a key to your home?

Yes

Emergency Person 2*

Name*

Phone (Home)*

Phone (Work)*

Phone (Cell)*

Email*

Are they local?

Yes

Does this person have a key to your home?

Yes

Access to the Home

Do you live in an apartment complex?

Yes

Is there an intercom on the building?

Yes

Are you providing a key to your apartment building?

Yes

Do you have a door which faces the outside so a volunteer can knock on it?

Yes

Are you providing a key to your house or individual apartment?

Yes

Do you have pets?

Dog

Cat

Other

Do you need help obtaining pet food? (For Dogs and Cats ONLY)*

Service Eligibility

I am homebound *

I am unable to prepare my own meals *

Do you have any medical, mobility, hearing, vision or communication issues we should know about? *

Will you need help opening packages, cutting food, etc.?

Yes

If yes, please explain: *

Does anyone else live in the home with you?

Yes

Who else lives in the household? *

Do you have access to a refrigerator?

Yes

Do you have access to a freezer?

Yes

Disaster Risk

If MOWCM was unable to deliver food to you for 1 to 3 days due to severe weather or for other reasons:*

Would you have sufficient food in your home up to for 3 days?

Yes

Could a family member or friend be counted on to get food to you?

Yes

Monthly Income Information

Alternative: Pay full amount of $16.38, no financial disclosure required *

Please note: full pay for meals is $15 per day, which includes 2 meals delivered by a friendly volunteer. *

Client Income (include Social Security, Pension, Dividends, Interest, etc.) *

Food Stamps (Meals on Wheels accepts food stamps) *

Housing Expenses (include rent, mortgage, taxes, insurances, and HOA's) *

Utilities Expenses (gas, oil, electric, water) *

Medical Expenses (doctors, medicine, home nursing care, depends, seeing eye dog, premiums, etc.) *

Other Expenses *

Please Specify Other Expenses*

Number of people in the household supported by this income:*

Payment

Person responsible for paying bill: *

Address*

Preferred Phone*

Phone *

Referral Information

Do you have a social worker or case manager assisting you from another agency?

Yes

Name*

Agency*

Address*

Phone *

How did you hear about Meals on Wheels?*

Other:*

About Us
Programs
Volunteer
Giving
Events
- Culinary Experience
- Thanks for Giving 2018
Contact Us
Online Community
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515 South Haven Street, Baltimore, Maryland 21224 | 410.558.0827 | 410.558.1321 fax

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Programs
Volunteer
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Events
- Culinary Experience
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