Application for Services | Meals on Wheels of the Sandhills

Current Client Information
Nutritional Risk Assessment
Household Information
Additional Information
Complete

NEED FOR SERVICE

What is your need for our services? Check all that apply.

Homebound

Living alone

Unable to cook

Unable to shop

No caregiver to cook

CLIENT INFORMATION

First name:

Last name:

Street address:

Apartment Number

Apartment Name

City:

State:

Zip code:

My residential address is:

Rural

Urban

Phone number:

Email address (if any):

Would you like to also receive email or text message notifications from Meals on Wheels?

Text

Email and Text

Call Only

Gender

Female

Male

Non-Binary

Declined to State

Other

Marital Status

Single

Married

Divorced

Widowed

Date of birth:

Race

Primary Language

Are you a veteran?

Yes

Which of the following best describes your current health or medical insurance coverage. Select all that apply.

Medicaid

Medicare

Private

Not Insured

Prefer not to answer

Other

Do you receive SNAP benefits?

Yes

Do you have a food allergy?

Yes

Please list food allergen(s)

Do you have a disability or impairment?

The Americans with Disabilities Act (ADA) defines a person with a disability as a person who has a physical or mental impairment that substantially limits one or more major life activity. This includes people who have a record of such an impairment, even if they do not currently have a disability. It also includes individuals who do not have a disability but are regarded as having a disability.

Please specify each impairment you may experience:

Questions	None	Some	Total
Hearing	None	Some	Total
Sight	None	Some	Total
Speech	None	Some	Total
Taste	None	Some	Total
Smell	None	Some	Total
Cognitive Difficulties	None	Some	Total

Do you use the following mobility aids? Select all that apply.

Cane

Walker

Wheelchair

Non-ambulatory

Does not use mobility aid

Prefer Not to Answer

Additional Information (if any)

How did you hear about Meals on Wheels of the Sandhills?

Other

Information message

×*Meals on Wheels of the Sandhills processes meal service applications on Tuesdays and Thursdays.*