Meals on Wheels Application

Applicant Information

(Please note: An application is required for each person applying for the program).  
Emergency Contact

Contact Instructions

Reason for needing Meals on Wheels
*To be eligible for services, an individual needs to meet the following criteria: Age 60 or older, homebound, unable to prepare meals, difficulty performing activities like bathing, dressing or shopping, and does not have an informal support system.  Those under 60 may utilize the program but would be required to pay $8.50 per meal.* 
Health Information


Nutrition Information
Prefer not to say
Activities of Daily Living
What level of assistance do you need with the following?
Independent Minimum Moderate Maximum Prefer not to say

Applicant Demographic Information

Yes No Prefer not to say