Client Application Form

Name of person filling out this application*

Email (for future correspondence)

Who should we contact to set up services? *
---Client directlyEmergency Contact 1Emergency Contact 2

Client Information

Name of client interested in receiving service *

Client Phone Numbers *

Address *

Which program is of interest?
HotFrozenBoth

Preferred language
EnglishFrench

Do you live alone?
YesNo

Medical Information

Health Card Number *

Date of Birth *

Reason for Meal program request

Allergies or Dietary Restrictions

Do you receive home care support?

Do we have your permission to share your personal health information with other agencies involved in the circle of care?
YesNo

Emergency Contacts

I give consent to Meals on Wheels to call the following emergency contacts:

Emergency Contact 1 *

Emergency Contact 2

How did you hear about Meals on Wheels?
Previous KnowledgeFamily/friend/volunteerAging in place coordinatorWebsiteHospitalOther:

If other, please specify

Do you have a Gift Certificate?
YesNo