Client Enrollment Form

 
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Do you have pets?
What type of meal do you want?

EMERGENCY CONTACTS

PLEASE CHECK THAT YOU HAVE READ AND UNDERSTAND THE FOLLOWING
Meals on Wheels utilizes volunteer drivers to deliver your meal and are not trained in home health care so are unable to assist in any medically -based tasks including dressing, moving clients, etc.
I UNDERSTAND THAT BY TYPING OR SIGNING BELOW, I ACKNOWLEDGE AND CONFIRM THAT ALL OF THE INFORMATION I HAVE PROVIDED IN THE ENROLLMENT FORM IS TRUE AND COMPLETE

CLIENTS UNDER THE AGE OF 65 MUST HAVE A MEDICAL CONDITION PREVENTING THE ABILITY TO PREPARE MEALS AND BE HOMEBOUND