Golden Hearts Senior Hot Meal Program Intake- LHO

Golden Hearts Senior Hot Meal Program Intake- LHO
A Lively Hearts Organization Outreach Initiative
Service Area Notice:

This program currently serves seniors located in the Memphis & surrounding areas only.
Is the senior located in the Memphis or surrounding areas?*

YesNo
Thank you for your interest in our Golden Hearts Senior Hot Meal program. At this time, meal services are available only to seniors located in Memphis and surrounding areas. If you have any questions please contact us:
Website: https://livelyhearts.org

Ph.: 901-205-4557

Email: contact@livelyhearts.org
Program Eligibility Notice:

This program is NOT based on income and there is no income verification required to participate. Our Golden Hearts Senior Hot Meal Program is open to eligible seniors in the Memphis and surrounding areas, regardless of financial status or race. Our goal is to serve with dignity, love, and care.
Section 1: Contact Information
Name

First NameLast Name
Phone Number (area code first)
Please enter a valid phone number.
Email Address (optional)
*If you do not have an email address, you may leave this blank.
Physical Delivery Address
*This is the address where meals will be delivered.
Date of Birth

MonthDayYear
Date
Section 2: Eligibility Details
Age Confirmation*
By submitting this form, I confirm that I am age 60 or older.
Living Situation

AloneWith familyWith caregiverOther
Do you have any disabilities or chronic health conditions?

YesNo
If yes, please explain:
Section 3: Needs & Services
*Some services are based on availability and future program expansion.
What services do you currently need? (Check all that apply).

Friday Hot Meal Delivery (2nd & 4th Fridays)Spiritual supportFriendly VisitsOther
How often would you like support?

WeeklyBi-weeklyMonthlyOther
Dietary Restrictions, Allergies, Etc...
Do you have any dietary restrictions or food allergies that we should be aware of? (Ex.: diabetic-friendly, low sodium, allergies, no pork, soft foods, etc)
*Meals are prepared based on availability. While we do our best to accomodate dietary needs, we may not be able to meet all special requests.
Section 4: Emergency Contact
Emergency Contact Name

First NameLast Name
Emergency Contact Relationship (example: daughter, brother, friend, etc.)
Emergency Contact Phone Number (area code first)
Please enter a valid phone number.
Section 5: Additional Notes & Consent
Is there anything else you'd like for us to know?
Lively Hearts Organization respects your privacy. The information collected on this form is used ONLY on coordinate meal delivery services, ensure participant safety, and communicate program-related updates.

We do NOT sell, share, or misuse personal information. Information be used in non-identifying, aggregate form (such as total number of seniors served) for reporting to funders and community partners.
Do you agree to allow Lively Hearts Organization to contact you and coordinate services on your behalf?

YesNo
Should be Empty:

Golden Hearts Senior Hot Meal Program Intake- LHO

Section 1: Contact Information

Section 2: Eligibility Details

Section 3: Needs & Services

Section 4: Emergency Contact

Section 5: Additional Notes & Consent