Apply For Meals - Meals on Wheels Western Michigan

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Client Donation

Apply For Meals

To qualify for Home Delivered Meals, individuals must be 60 years or older, reside in Kent or Allegan County, and have a physical or mental limitation that prevents them from regularly preparing balanced meals or grocery shopping.

If you meet these qualifications, complete the form below to apply for nutritious meal delivery to your home. Please complete one form per applicant.

County

Date of Birth

First Name

Middle Initial

Last Name

Nickname

Street Address

City

State

ZIP Code

Township or Municipality

Apartment Complex Name (if any)

Mailing Address (if different than above)

Mailing Address City

Mailing Address State

Mailing Address ZIP Code

Home Phone

Cell Phone

Email

Gender

Preferred Pronouns

Is the client transgender or gender non-conforming?

Sexual orientation

Race

Is the client Hispanic?

Additional Information

Does the client speak English?

If no, which language is spoken?

Marital Status

Is the client a veteran?

How many people are in the household?

Gross Monthly Income

What is the living arrangement?

Does the client drive?

If yes, please describe.

Does the client have trouble standing to prepare a meal?

Does the client have trouble grocery shopping independently?

Does the client have trouble chewing or swallowing food?

Has the client been hospitalized overnight in the last 30 days?

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?

If the client is undergoing dialysis, Please indicate which days.

Please list any other known diagnosis/health concerns.

"*" indicates required fields

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Client Contact Information

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*

If Other, input your personal pronouns here.

Transgender or gender non-conforming?*

Sexual orientation*

Address*

Street Address City State ZIP Code

Township/Municipality

Apartment or Complex Name (If Any)

Mailing Address (If different):

Street Address Address Line 2 City State ZIP Code

Home Phone*

Cell Phone

Email Address

Race*

Hispanic?*

Additional Information*

Does the client speak English?*

If No, which language is spoken?

Additional Client Information

Marital Status*

Veteran?*

Household Size*

Gross Monthly Income*

Living Arrangement*

Does the client drive?*

If yes, please describe:

Does the client have trouble standing to prepare a meal?*

Does the client have trouble grocery shopping independently?*

Does the client have trouble chewing or swallowing food?*

Has the client been hospitalized overnight in the last 30 days?*

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?

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*

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

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*

Does the client desire milk with the meals?*

If yes, which Type of Milk?

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?*

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Suite 500
Grandville, MI 49418

Phone: (616) 459-3111
Fax: (616) 224-0220
info@mowwm.org
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