Meals on Wheels and More

Client Interest Form

If you are filling out this form on behalf of someone else, please tell us your name and your connection to the person interested in receiving services.

Information about person interested in receiving services

First Name

Last Name

Age or Date of Birth

Contact Information

Phone

Address Line 1

Address Line 2

City

State

Zip Code

What are the reasons for needing this service?

Did anyone refer you to Meals on Wheels and More? If so, who?

What is the best time for us to call you?

Is anyone else in your home already receiving services from Meals on Wheels and More?

Please tell us who is already receiving services in your home:

Is anyone else in the home interested receiving services from Meals on Wheels and More?

Please tell us who else is interested in receiving services in the home:

Cancel Your Meal Delivery

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Programs

Meals on Wheels »Volunteers deliver meals to homebound clients
Second Meals »Additional meals delivered to clients who are most nutritionally at-risk
Veterans Services »Specialized care designed to meet the unique challenges and circumstances military veterans often face
PALS »Volunteers transport clients’ pets for vet visits or deliver pet food monthly.
Home Repair »For clients whose homes face serious structural issues related to health & safety
Meals for Kids »Nutritious evening meals provided to low-income children
Mike's Place »Volunteers help clients with Alzheimer's Disease and other forms of dementia
Country Wheels »Seven frozen meals delivered once a week to clients living in rural areas
HOPE »Volunteers deliver an extra bag of groceries once a month
Congregate Meals »A place for active seniors to gather for games, physical activity, conversation and lunchtime meals
Handy Wheels »Volunteers help clients with minor home repairs that are safety-related.
Groceries to Go »Volunteers grocery shop twice a month for clients