Meals on Wheels Application

Applicant Information

How would you like your name to display on receipts?

(A separate 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 $9.00 per meal.* 
Health Information


Nutrition Information
Activities of Daily Living
What level of assistance do you need with the following?
Independent Minimum Moderate Maximum

Applicant Demographic Information

Yes No