Meals on Wheels Request Form - Island Senior Services

NOTE: Delivery of meals will not begin until you have talked to a staff member who will collect other necessary information before you begin.

Client / Recipients Legal Name

First NameLast Name

Home Phone Number

Format: (000) 000-0000.

Cell Phone Number

Format: (000) 000-0000.

E-mail

example@example.com

What is your preferred method of contact?

Address

Street Address

Apt / Unit number

CityState

Zip Code

Date of Birth

Does the participant have a Medicaid / COPES case manager?

Name of Medicaid / COPES Case Manager?

EMERGENCY CONTACT INFORMATION

Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Emergency contact preferred method of contact?

Relationship to Recipient

MEAL DELIVERY

I would like to discuss receiving Ensure (must be 60 years or older)

Deliveries occur every Monday, Wednesday and Friday. We deliver hot and frozen meals each delivery day. Please include any Meal Delivery Instructions, if any:

DIETARY OPTIONS

I have the following dietary restrictions:

If you are not eligible for home delivery, please join us at a meal site (Camano, Oak Harbor, Coupeville, Langley) where hot and frozen meals are available. Island Senior Resources is dedicated to providing healthy and delicious meals to those in need, living in Island County. We are committed to supporting the well-being of community by delivering nutritious meals directly to their doors.

To ensure that services continue without a waiting list, Island Senior Resources asks all meal recipients to consider making a contribution of any amount toward this service. Each meal costs over $12.50 to prepare and deliver. Any contribution received helps sustain this important service to the community.

For those who are unable to contribute at this time, Island Senior Services assures that meal delivery will continue without interruption — though this may be subject to change depending on future decisions at the federal level.

After you click Submit, you will receive an email confirmation.