Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Year 2018 2019 2020 2021 2022
CLIENTS UNDER THE AGE OF 62 MUST HAVE A MEDICAL CONDITION PREVENTING THE ABILITY TO PREPARE MEALS AND BE HOMEBOUND. MEDICAL VERIFICATION MUST BE INCLUDED WITH YOUR APPLICATION. Email your verification to firstname.lastname@example.org.
Head of Household ( responsible for minor children)
- Select - White Non Hispanic Hispanic Black Asian American Indian Native Hawaii Other or decline to answer
Race or Ethnicity
How did you hear about Meals on Wheels ?
Billing Information (If different from applicant). Please include name, address, and phone number
I would like my bill emailed - Go green (email address)
I would like my bill mailed
Would you like to be considered for a reduced fee?
If you would like to be considered for a reduced fee, we require documentation of your gross monthly Income (such as a bank statement, direct deposit info, social security statement, etc, ). Please include a copy with your application. Email your verification to email@example.com.
Have you ever received Meals on Wheels before?
Why do you need the services of Meals on Wheels at this time?
- Select - Regular Large Regular Vegetarian Dental Soft Renal Pureed
What type of meal would you like?
Number of Meals per delivery
You may choose up to 3 meals per delivery
Are you able to answer the door?
Special Delivery Instructions (hard of hearing, uses walker, etc)
Do you have pets?
Do you have pets?
If yes, what kind and the name of your pet
Do you have one of the following working with you?
Social Worker/Case Manager Name
Phone Number for Social Worker or Case Manager
PLEASE PROVIDE 2 EMERGENCY CONTACTS- Local please
Contact #1 - Name and Relationship
Contact #1 - Address, City, State, Zip
Contact #1 - Phone and Email
Contact #2 - Name and Relationship
Contact #2 - Address, City, State, Zip
Contact #2 - Phone and Email
PLEASE CHECK THAT YOU HAVE READ AND UNDERSTAND THE FOLLOWING
Meal cancellations or additions must be called in no later than 1:00 pm the business day prior to the delivery
Meal delivery is normally between 11:30 and 12:30. Please note that weather, traffic, etc. may affect delivery time.
If you will not be home at time of delivery, please call the office to let us know you will not be home and leave a cooler outside for your meal. If you receive a message from us, please call us to let us know you have received your meal and are ok. If we do not hear from you and cannot reach you, we will attempt to contact your emergency contact(s) or contact the non-emergency police to do a wellness check, if necessary.
Drivers are only able to deliver meals.
Meals on Wheels utilizes volunteer drivers to deliver your meal and are not trained in home health care so are unable to assist in any medically -based tasks including dressing, moving clients, etc.
I hereby grant and convey unto Meals on Wheels for Fort Collins, CO, Inc., all rights, title and interest in any and all photographs, video or audio recordings of or including my image or voice, used in any publications, news releases, online and in other communications related to the mission of Meals on Wheels for Fort Collins. (optional )
Desired Start Date
Meals on Wheels for Fort Collins does not discriminate on the grounds of race, color, national origin, religion, creed, disability, age, sex, actual or perceived sexual orientation, gender identity, marital status, familial status, or because a family includes children.
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.