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Apply For Meals
Fill out the form below to apply to have nutritious meals delivered right to you. Please complete one form per applicant.
County
Kent County
Allegan County
Date of Birth
First Name
Middle Initial
Last Name
Nickname
Street Address
City
State
AL
AK
AS
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
MP
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VT
VA
VI
WA
WV
WI
WY
ZIP Code
Township or Municipality
Apartment Complex Name (if any)
Mailing Address (if different than above)
Mailing Address City
Mailing Address State
AL
AK
AS
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
MP
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VT
VA
VI
WA
WV
WI
WY
Mailing Address ZIP Code
Home Phone
Cell Phone
Email
Gender
Male
Female
Other
Preferred Pronouns
Is the client transgender or gender non-conforming?
Yes
No
Prefer not to say
Sexual orientation
Straight/heterosexual
Lesbian
Gay
Bisexual
Other
Prefer not to say
Race
American Indian/Eskimo
Asian
Black
Hawaiian/Pacific Islander
Latino/Hispanic
White
Unknown
Is the client Hispanic?
Yes
No
Unknown
Additional Information
Tribal
Multi-racial
None
Does the client speak English?
Very well
Well
Not well
Not at all
If no, which language is spoken?
Marital Status
Single
Married
Widowed
Divorced
Separated
Unknown
Is the client a veteran?
Yes
No
Unknown
How many people are in the household?
Gross Monthly Income
What is the living arrangement?
Alone
With Spouse
With Family
Other
Unknown
Does the client drive?
Yes
No
If yes, please describe.
Does the client have trouble standing to prepare a meal?
Yes
No
Does the client have trouble grocery shopping independently?
Yes
No
Does the client have trouble chewing or swallowing food?
Yes
No
Unknown
Has the client been hospitalized overnight in the last 30 days?
Yes
No
Unknown
Does the client have any of the following conditions?
Arthritis
High Blood Pressure
Heart Disease
Cancer
Diabetes
Kidney Disease
Dialysis
COPD
Dementia
Depression
Anxiety
Other Mental Illness
None
If Kidney Disease, which stage is the client currently in?
1
2
3
4
5
If the client is undergoing dialysis, Please indicate which days.
Please list any other known diagnosis/health concerns.
Send
"
*
" indicates required fields
Step
1
of
3
33%
Client Contact Information
County
*
Select One
Kent County
Allegan County
Our service area includes Kent and Allegan Counties. If you live outside these counties, please follow this URL to find services in your county. https://www.osapartner.net/miseniors/Default.aspx
Your Name
*
First
Middle Initial
Last
Nickname
Date of Birth
*
MM slash DD slash YYYY
Gender
*
Select One
Male
Female
Other
If Other, input your personal pronouns here.
Transgender or gender non-conforming?
*
Select One
Yes
No
Prefer not to say
Sexual orientation
*
Select One
Straight/Heterosexual
Lesbian
Gay
Bi-sexual
Other
Prefer not to say
Address
*
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Township/Municipality
Apartment or Complex Name (If Any)
Mailing Address (If different):
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Home Phone
*
Cell Phone
Email Address
Race
*
Select One
White
Black
American Indian / Eskimo
Asian
Hawaiian / Pacific Islander
Unknown
Hispanic?
*
Select One
Yes
No
Unknown
Additional Information
*
Select One
Tribal
Multi-Racial
None
Does the client speak English?
*
Select One
Very Well
Well
Not Well
Not At All
If No, which language is spoken?
Additional Client Information
Marital Status
*
Select One
Single
Married
Widowed
Divorced
Separated
Unknown
Veteran?
*
Select One
Yes
No
Unknown
Household Size
*
Select One
1
2
Gross Monthly Income
*
Living Arrangement
*
Select One
Alone
Spouse
Family
Other
Unknown
Does the client drive?
*
Select One
Yes
No
If yes, please describe:
Does the client have trouble standing to prepare a meal?
*
Select One
Yes
No
Does the client have trouble grocery shopping independently?
*
Select One
Yes
No
Does the client have trouble chewing or swallowing food?
*
Select One
Yes
No
Unknown
Has the client been hospitalized overnight in the last 30 days?
*
Select One
Yes
No
Unknown
Does the client have any of the following conditions?
*
Arthritis
High Blood Pressure
Heart Disease
Cancer
Diabetes
Kidney Disease
Dialysis
COPD
Dementia
Depression
Anxiety
Other Mental Illness
None
Check all that apply.
If Kidney Disease, which stage is the client currently in?
Select One
1
2
3
4
5
If the client is undergoing dialysis, Please indicate which days.
Other known Diagnosis/Health concerns?
Emergency Contact 1
Emergency Contact Name
*
Emergency Contact Address
Emergency Contact Email
Emergency Contact Phone
*
Emergency Contact Phone Type
*
Select One
Home
Work
Mobile
Emergency Contact Relationship
*
Emergency Contact 2
Emergency Contact 2 Name
Emergency Contact 2 Address
Emergency Contact 2 Email
Emergency Contact 2 Phone
Emergency Contact 2 Phone Type
Select One
Home
Work
Mobile
Emergency Contact 2 Relationship
Case/Care Manager
Case/Care Manager Phone
Case/Care Manager Agency
Physician Name
Physician Phone
Additional Client Information
Type of Meals Desired
*
Select One
Hearty
Choice
Cut
Minced & Moist
Puree
Does the client desire milk with the meals?
*
Select One
Yes
No
If yes, which Type of Milk?
2%
Skim
Chocolate
Any Additional Information for the Delivery Driver?
This form was completed by:
*
Your relation to the client
*
Your phone number
*
Who would you prefer we contact regarding this referral?
*
