Client Referral Form

Alamance County Meals on Wheels Application Form

Fill in your personal details in the required sections.
Are you 60 years old or older?
How many people in your household?
If you answered more than 1 person in your household, how old are the others that live with you?
Are you able to drive?
Are you able to cook/prepare meals?
Do you have less than 20 hours of in home aid per week?
Do you have memory or cognitive issues? (Alzheimer's/Dementia)
Personal Information
Full Name

First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Current Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Date of Birth

MonthDayYear
Government ID
Last four SS#
Male or female
Marital Status
Race
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Relationship
Each meals costs $7.00. Is that something that you could pay out of pocket?
If you are not able to pay for your meals, we do have a grant that would pay for them. Would you like to choose this option?
Who referred you?
We currently have a waiting list. Please note that it may be weeks to months before you are contacted. Once there is space available, you will receive a phone call from our Client Care Coordinator. Thank you
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Alamance County Meals on Wheels Application Form