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Meal Program Application
Tower Community Support is now providing free nutritious meals for eligible Medicaid members in Brooklyn, Manhattan and Queens. Meals are available for individuals with medical, mental health, or functional conditions, including pregnant and postpartum women and families with chronic conditions.
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Street Address
*
Apt / Unit
Building Code
Floor Number (example: 23)
Building Directions
City
*
Please Select
Brooklyn
Manhattan
Queens
State
*
Please Select
NY
Zip Code
*
Home Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Select all that apply
Enrolled in Health Home Care Managment
Substance Use Disorder diagnosis
Serious Mental Illness diagnosis
Child under 18 with a choronic condition
Other medical / mental health condition
Expecting / Is the eligible member pregnant?
*
Yes
No
Postpartum / Do you have a baby under the age of one?
*
Yes
No
Are you employed?
*
Yes
No
Is your spouse employed?
Yes
No
N/A
Do you receive WIC?
Yes
No
Do you receive SNAP?
Yes
No
Please specify other caterer
Select all Dietary Restrictions that apply
Halal Meals
Fresh Produce
Dairy Products
Non-Perishable Foods
Prepared Meals
Infant Formula
Baby Food
Gluten-Free Options
Low-Sodium Options
Kosher Meals
Other
Other Needs / Comments
FOOD SUPPLIES (You might qualify for the items listed below. Please check which ones you need.)
Cooking supplies
Refrigerater
Microwave
Do you have additional household members?
*
Yes
No
How many additional household members?
*
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Member 1
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Member 2
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Member 3
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Member 4
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Member 5
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Member 6
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Member 7
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Member 8
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Member 9
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Member 10
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Member 11
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Member 12
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Member 13
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Member 14
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Member 15
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: