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Application for Service
Client Information
First Name
*
Last Name
*
M.I.
*
Gender
Male
Female
*
Ethnicities
<Select>
African-American
Asian
Caucasian
Hispanic
Native American/Alaskan
Other, Unreported
Refuse to Answer
*
Address
*
City
*
Zip Code
*
County
<Select>
Anne Arundel County
Baltimore City
Baltimore County
Carroll County
Frederick County
Harford County
Howard County
Montgomery County
Prince George's County
*
Birthdate
*
Social Security #
*
Phone (Home)
*
Phone (Cell)
*
Email
*
Language Spoken
<Select>
English
Spanish
Other
*
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.?
<Select>
Yes
No
*
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
No
*
Does this person have a key to your home?
Yes
No
*
Emergency Person 2
*
Name
*
Phone (Home)
*
Phone (Work)
*
Phone (Cell)
*
Email
*
Are they local?
Yes
No
*
Does this person have a key to your home?
Yes
No
*
Access to the Home
Do you live in an apartment complex?
Yes
No
*
Is there an intercom on the building?
Yes
No
*
Are you providing a key to your apartment building?
Yes
No
*
Do you have a door which faces the outside so a volunteer can knock on it?
Yes
No
*
Are you providing a key to your house or individual apartment?
Yes
No
*
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
No
*
If yes, please explain:
*
Does anyone else live in the home with you?
Yes
No
*
Who else lives in the household?
*
Do you have access to a refrigerator?
Yes
No
*
Do you have access to a freezer?
Yes
No
*
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
No
*
Could a family member or friend be counted on to get food to you?
Yes
No
*
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
<Select>
Home
Work
Cell
*
Phone
*
Referral Information
Do you have a social worker or case manager assisting you from another agency?
Yes
No
*
Name
*
Agency
*
Address
*
Phone
*
How did you hear about Meals on Wheels?
<Select>
Service Agency/Case Worker
Church
Current or Past Client
Physician/Nurse
Publicity
Current or Past Volunteer
Hospital
Family/Friend
Nursing Home
Website
Previously Received Meals
Other
*
Other:
*
About Us
Mission & History
Media Coverage
Newsletters
Annual Report
Board of Directors
Employment
More than a Meal Blog
Programs
Home Delivered Meals
Support Services
Client Stories
Grocery Assistance Program
Group Meal Programs
Menus & Pricing
New Initiatives
Housing Upgrades to Benefit Seniors (HUBS)
Together in Care Program
Volunteer
Frequently Asked Questions
Volunteer Delivery Opportunities
Additional Volunteer Opportunities
Corporate/Group Opportunities
Service Projects
Volunteer Orientation
Volunteer Resources
Volunteer Application
Court-Appointed Community Service Application Form
Giving
Give Online
Monthly Giving
Memorial/In Honor Giving
Personal Fundraising
Unwined Candles
Planned Giving
Matching Gifts
Workplace Giving
Gifts of Stock
Car Donations
Corporate Sponsors
ViaSat Donation Form
Events
Culinary Experience
Thanks for Giving 2018
Contact Us
Online Community
My Email Preferences
Privacy Policy
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