BNDK PURPOSEFUL PLATES
20 - Meal Support Program Application
Applicant Info
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Method of Contact
*
Please Select
Phone
Email
Text
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Street Address
*
City Name
*
Zip Code
*
Are you applying for:
*
Yourself
A Child
A family member
Multiple people in your household
Medical Qualification
Which of the following are you currently experiencing? (select all that apply)
*
Heart condition
Diabetes / blood sugar issues
High blood pressure
Kidney disease
Cancer treatment or recovery
Eating disorder recovery
Severe food allergies
Autoimmune condition
Other
Have you been diagnosed by a medical professional?
*
Yes
No
Currently in the process
(For Cardiac Support Applicants ONLY) Do you have at least 3 of the following? High blood pressure, Diabetes, Obesity, History of Heart Disease, BMI >27?
Yes
No
Not sure
(For Oncology Support Applicants ONLY) Select All that apply
Undergoing chemotherapy or radiation (able to eat normally)
In post - treatment recovery
Experiencing treatment - related weight loss
Medically stable with provider oversight
None of these apply to me
(For Renal Support Applicants ONLY) Select All that apply
Stage 2 - 3 chronic kidney disease
Early Stage 4 (with provider approval)
Not on dialysis
None of these apply to me
(For Eating Disorder Recovery Applicants ONLY) Select All that apply
In outpatient or post - residential recovery
Medically stable
Cleared by provider
None of these apply to me
Do you have any food allergies or religious preferences? Select all that apply
Peanuts
Tree nuts
Milk
Eggs
Fish
Shellfish
Wheat
Soy
Halal
Vegan
Other
Who is your Physician or Healthcare Provider?
Program Details
Meal Delivery Schedule: Meals are prepared and delivered by Burns in the Kitchen once per week on Mondays between 9:00 AM - 3:00 PM. At this time, we are unable to offer alternate delivery days or times. We do offer cold packs in each order.
Are you available to receive meals on Mondays, between 9:00 AM - 3:00 PM
*
Yes
No
If you are unavailable during delivery hours, what is your backup plan?
*We recommend having a cooler out front every Monday morning for delivery or we can place meals in garage refrigerator, if applicable.
Each meal is: Designed to support common health conditions, allergy - conscious based on the information you provide, and fully prepared and ready to enjoy. DO YOU UNDERSTAND AND AGREE TO RECEIVE STANDARDIZED MEALS AS PART OF THIS PROGRAM?
*
Yes, I understand
I have questions
*Participants who continue with BNDK PURPOSEFUL PLATES as part of our Alumni Program or through extended support may have access to more customized meal options.
Story Section
What is your current household income range
Please Select
Under $25,000
$25,000 - $50, 000
$50,000 - $75,000
$75,000+
Which best describes your current situation?
*
Unable to work due to health
Reduced income due to medical condition
High medical expenses
Caregiver for someone in need
Other
Tell us about your current situation.
*
How would receiving 20 prepared meals (5 meals/week for 4 weeks) impact your life?
*
If selected, would you be willing to fill out an Intake form Before and After your 20 prepared meals ( 5 meals/week for 4 weeks) has been completed?
*
Please Select
Yes
No
If selected, would you be open to sharing your story with donors?
*
Please Select
Yes, I'd be open to it
Maybe, I'd like more information
No, I prefer to stay private
Sharing your story helps us continue supporting others like you.
Help Us Measure the Impact of Your Meals
To continue providing meals to others, we track how support impacts health and daily life. This helps us improve care and share outcomes with donors and healthcare partners.
How would you rate your current energy levels?
*
Very low
Low
Moderate
Good
High
Which areas are you currently struggling with most? (Select up to 3)
*
Energy / Fatigue
Managing my condition through food
Time to cook or prepare meals
Financial access to healthy food
Stress around meals
Other (Please share below)
Share Comments if selected Other
What are you hoping will improve over the next few weeks with meal support?
*
If selected, do you agree to complete a short follow - up form after receiving your 20 meals?
*
Please Select
Yes, I'm happy to help
Maybe, I'd like more information
Consent + Agreement
Before submitting, please confirm:
The information I provided is accurate to the best of my knowledge
I understand this is an application and not a guarantee of support
I agree to be contacted regarding my application
Submit
Should be Empty: