COVID-19 Relief Meal Delivery Request Form
for Residents of the City of District Heights
In an effort to provide relief to the seniors, veterans and disabled residents in the City of District Heights, The Office of the Mayor has partnered with Carolina Kitchen to sponsor hot meal deliveries once a week on Wednesdays (Noon-2:00pm). Please complete the form below to submit your request.
Questions? Contact Montré Dupree, (301) 531-5182 or email, dhcityevents@gmail.com
Order Date
*
-
Month
-
Day
Year
Date
Order Type
*
Seniors 65+
Veteran
Person with a Disability
Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Delivery Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Meals Delivery Schedule
Noon - 1:00 pm
1:00 pm -2:00 pm
# of Meals Requested
(Max 2 per Household)
Preferred Delivery
1
2
Special instructions (include any dietary restrictions)
Emergency Contact
First Name
Last Name
Emergency Contact Phone Number
-
Area Code
Phone Number
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NOTES/REMINDER:
Please be sure to let us know if there will be a change in your meal delivery time.
Meals will be delivered once a week on Wednesday through December 31, 2020.
Submit
Print Form
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