HOW DID YOU HEAR ABOUT MEALS ON WHEELS ARIZONA WHITE MOUNTAINS?
NAME
BIRTHDATE
/
Month
/
Day
Year
Date
ADDRESS
PHONE NUMBER
GENDER
FEMALE MALE
MALE
EMAIL
example@example.com
CLIENT ETHNIC STATUS
WHAT LANGUAGE DO YOU SPEAK?
ARE YOU A VETERAN??
YES
NO
EMERGENCY CONTACT PERSON
RELATION TO CLIENT
EMERGENCY CONTACT PHONE NUMBER
DO YOU LIVE ALONE?
YES
NO
OTHER
ARE YOU THE HEAD OF HOUSEHOLD?
YES
NO
OTHER
DO YOU LIVE IN THE ARIZONA WHITE MOUNTAINS FULL TIME?
YES
NO
DO YOU HAVE ANY ANIMALS? (CHECK ALL THAT APPLY)
NO
YES
DOG
CAT
SM
LG
DO YOU NEED HELP ACCESSING DOG/CAT FOOD?
YES
NO
DO YOU HAVE TROUBLE HEARING?
YES
NO
DO YOU HAVE ANY MEDICAL CONDITIONS YOU TAKE PRESCRIPTION MEDICATION FOR?
YES
NO
DO YOU HAVE ANY DISABILITIES WE SHOULD KNOW ABOUT?
CAN YOU DRIVE?
YES
NO
WILL YOU NEED HELP TO EVACUATE IN CASE OF ANOTHER WILDFIRE?
YES
NO
AS A SELF-PAY INDIVIDUAL FOR MEALS ON WHEELS ANY CONTRIBUTION YOU CAN MAKE ALLOWS US TO NOT ONLY FEED YOU BUT TO FEED OTHERS WHO ARE IN NEED. EACH MEAL IS $7.00. HOW MUCH CAN YOU CONTRIBUTE TOWARDS YOUR MEAL?
WHEN WOULD YOU LIKE TO BE BILLED?
DAILY
WEEKLY
MONTHLY
IS SOMEONE SPONSRING YOUR MEALS?
YES
NO
NAME
PHONE
WHAT INSURANCE DO YOU HAVE?
MEDICARE/PRIVATE
ALTEC/MEDICAID
TRICARE
NONE
IF YOU HAVE AN AHCCCS MEDICARE PLANS PLEASE SELECT THE ONE BELOW.
ST CARE 1 HEALTH PLAN OF ARIZONA
HEALTH CHOICE ARIZONA BLUE CROSS BLUE SHIELDS ARIZONA
DATE
/
Month
/
Day
Year
Date
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