Meal Application

In order to help us process your application as quickly as possible, please ensure that all information is included before you submit. If you have any questions, please call Client Services at 325-655-9200 Ext. 111.

An incomplete application can cause a delay in the approval process.

Date*

Date of Application

Referred by

Referrer's Phone Number

Area CodePhone Number

Recipient Name*

First NameLast Name

Age*

Date of Birth*

Date of Birth

Address*

Street Address

Street Address Line 2

CityState

Postal / Zip Code

Phone Number*

Area CodePhone Number

Primary Language*

Email

[email protected]

Has the applicant ever received Meals For The Elderly before?*

YesNo

Home Health Provider

Home Health Provider Phone Number

Area CodePhone Number

What hours is the home health provider in the home? (Please put a time next to the days)

Monday

Ex: 3pm-4pm

Tuesday

Ex: 8am-10am

Wednesday

Ex: 3pm-4pm

Thursday

Ex: 8am-10am

Friday

Ex: 3pm-4pm

Doctor's Name*

Doctor's Phone Number*

Area CodePhone Number

List health problems*

Ex: COPD, Diabetes, Unsteady Gait, Fractured Hip, etc.

Disabled*

YesNo

Condition*

PermanentTemporary

Length of Temporary Condition

Diet Type*

RegularDiabetic

If married, is spouse interested in applying for MFTE?*

YesNoSingleWidowed

Spouse's Name*

First NameLast Name

Age*

Date of Birth*

Date of Birth

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

Primary Language*

Email

[email protected]

Has the applicant ever received Meals For The Elderly before?*

YesNo

Home Health Provider

Home Health Provider Phone Number

Area CodePhone Number

What hours is the home health provider in the home? (Please put a time next to the days)

Monday

Ex: 10am-12pm

Tuesday

Wednesday

Ex:10am-12pm

Thursday

Friday

Ex:10am-12pm

Doctor/Physician*

Doctor/Physician Phone Number

Area CodePhone Number

List health problems*

Ex: Diabetes, Breast Cancer, Rheumatoid arthritis, Osteoarthritis, etc.

Disabled*

YesNo

Condition*

PermanentTemporary

Length of Temporary Condition

Diet Type*

RegularDiabetic

Next of Kin*

First NameLast Name

Relation*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Phone Number*

Area CodePhone Number

Work Phone Number

Area CodePhone Number

Cell Phone Number

Area CodePhone Number

Emergency Contacts:

Can be neighbor, relative, or friend (At Least 2, must be different from next of kin)

List Name's, Relation to You, Home and Work Numbers *

Ex: Ronnie Seal, Brother, Cell (325)123-4567 Work (325) 456-1234

Number of Cats

Number of Dogs

If eligible, would you like to receive supplemental pet food?

YesNo

Contributing for Meals

YesNo

By Whom? Family/Self

Are you a Veteran or a spouse of a Veteran?*

YesNo

If yes, veteran of?

Do you currently receive VA benefts?

YesNo

Do you have Medicare or Medicaid?*

MedicareMedicaidNone

Do you have any other insurance?*

YesNo

Insurance Company

Company from which you retired from?

Did the Company from which you retired from have a Matching Donation Program?

YesNo

Description of House/Location*

Ex: Corner red brick house off of Chadbourne & 19th St.

Additional Comments

Meal Application

Meals For The Elderly Recipient Application