Name of person filling out this application*
Email (for future correspondence)
Who should we contact to set up services? *
---Client directlyEmergency Contact 1Emergency Contact 2
Name of client interested in receiving service *
Client Phone Numbers *
Which program is of interest?
Do you live alone?
Health Card Number *
Date of Birth *
Reason for Meal program request
Allergies or Dietary Restrictions
Do you receive home care support?
Do we have your permission to share your personal health information with other agencies involved in the circle of care?
I give consent to Meals on Wheels to call the following emergency contacts:
Emergency Contact 1 *
Emergency Contact 2
How did you hear about Meals on Wheels?
Previous KnowledgeFamily/friend/volunteerAging in place coordinatorWebsiteHospitalOther:
If other, please specify
Do you have a Gift Certificate?
The first delivery of frozen meals was made on April 25th, 1991.