We Deliver Quality of Life

Application for Service

Client Information *

    * Required fields





    County:



    Birth date: (XX/XX/XXXX)

    Race:

    Ethnicity:

    How did you hear about Meals on Wheels of Central Maryland? *
    (hold CTRL/Command to select multiple)

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

    Emergency Contact:



    What Program are you applying for? *

    Reason for needing assistance: *

    I am homebound *

    I am unable to shop or cook for myself *

    Have you ever served in the military? *

    Has your spouse ever served in the military? *

    Health, mobility or dietary concerns we should be aware of:

    Special dietary needs for delivered meals:

    When would you like to begin service? (Please allow 3 business days)

    Enter date: (XX/XX/XXXX)

    Days Requested: * (hold CTRL/Command to select multiple)

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

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

    Social Worker Info:



    MONTHLY INCOME (Include all sources): *

    Please note: This information helps us determine a manageable fee based on your income and expenses. Please be prepared to provide your MONTHLY income and MONTHLY expenses during the scheduled telephone intake. Although documentation is not required, it is important that you report both your full income and all your expenses accurately. Failure to report all sources of income may result in an inability to initiate services.

    Please be prepared with the following information for our follow up call:

    • BGE
    • Personal Medical Care: In-Home aides, ensure/boost, depends etc.
    • Housing: Rent or Mortgage
    • Rx/prescriptions cost
    • Oil: heating (winter months)
    • Medical/Doctor: Co-pays
    • Telephone/Cable
    • Transportation
    • Taxes: Property, Outstanding IRS (Please specify)
    • Water
    • Insurance: Medical (out of pocket), Renters, Life or Homeowners (Please specify)

    Name and phone number of Person Completing application:


    In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, religious creed, disability, age, political beliefs, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.

    Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the agency (state or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

    To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: How to File a Complaint, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:

    1. mail: U.S. Department of Agriculture
    Office of the Assistant Secretary for Civil Rights
    1400 Independence Avenue, SW
    Washington, D.C. 20250-9410;

    2. fax: (833) 256-1665 or (202) 690-7442

    3. email: program.intake@usda.gov.

    This institution is an equal opportunity provider.

    02/06/2020

    Thank you for submitting your application. Someone from our office will contact you within 3 business days to schedule your telephone intake.

    *If you receive an error message when submitting this form, please call: 410-558-0827.

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