Meals on Wheels Client Application Form

Meals on Wheels Client Application Form
Application Date

MonthDayYear
Date
Requested meal delivery days*

MondayTuesdayWednesdayThursday
Client Name*

First NameLast Name
Client Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client Phone Number
Please enter a valid phone number.
Client Email
example@example.com
I (client) would like to receive more information about other Town House programs.

Yes, please.No thank you.
Who is the best person to contact regarding Meals on Wheels registration?*

ClientEmergency contact (listed below)Other caregiver/ family member (please provide)
If "other" please provide name/ relationship/ phone number.
Client Date of Birth*

MonthDayYear
Date
Special Delivery Instructions (use specific door, place in cooler, etc.)
Reason for Requesting Service (health concerns, mobility issues, etc.)
Dietary Restrictions

Financial Information

Sliding Scale Policy

Meals are billed at $5, $7, or $10, dependent on client income.
For clients in higher income brackets, meal prices will be closer to the actual production cost. Clients must provide a copy of their annual assessment to verify their annual income.

Household Income

At or below $25,000
$25,001 - $50,000
$50,000 or 3rd Party Orginazation

Amount You Pay

$5.00
$7.00
$10.00

Amount We Subsidize

$5.00
$3.00

Annual Income (approx. income if you don't have assessment close by)
I understand that I will need to show Town House staff a copy of most recent assessment in order to verify or update annual income before beginning meal delivery.*

YesNo
Please choose the payment option you would prefer

ChequeCash - at Town House officeDebit/ Credit - at Town House officeCredit - over the phoneETransfer
Emergency Contact Person*

First NameLast Name
Emergency Contact Relationship
Phone Number*
Please enter a valid phone number.
Email
example@example.com
I (emerg contact) would like to receive more information about other Town House programs.

Yes, please.No thank you.
Should be Empty: