We Deliver Quality of Life

Application for Service

Client Information

Gender

Days Requested

Special Requests

Are they local?

Does this person have a key to your home?

Are they local?

Does this person have a key to your home?

Do you live in an apartment complex?

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

Do you have pets?

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

I am homebound

I am unable to prepare my own meals

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

Does anyone else live in the home with you?

Do you have access to a refrigerator?

Do you have access to a freezer?

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

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

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

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

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