Client Application - Meals on Wheels of Central Maryland

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Application for Service

Client Information

First Name *

Last Name *

M.I. *

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 $15.98, 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:*

Screening for Additional Benefits

Does MOWCM have permission to provide your name, address, and phone number to our partner, Benefits Data Trust, to screen for and contact you regarding additional benefits you may be eligible for? *

Yes

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Programs
Volunteer
Giving
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515 South Haven Street, Baltimore, Maryland 21224 | 410.558.0827 | 410.558.1321 fax

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About Us
Programs
Volunteer
Giving
Events
- Culinary Experience
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