Other required information: Social Security number to be provided to Meals on Wheels prior to meal start date. What is your need for our services? Check all that apply. * Homebound Living alone Unable to cook Unable to shop CLIENT INFORMATION First name: * Last name: * Street address: * Apartment number Apartment Name City: * Michigan_City LaPorte Westville State * - Select -Indiana Zip code: * 46360 MC 46350 LP 46391 WV Phone number (home) * Phone number (mobile) * enter zero if no mobile phone Email address (if any): * Date of birth: * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year1918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020 Gender: * Female Male Ethnicity: * - Select -WhiteBlackHispanicAsian Marital Status: * - Select -MarriedWidowedSingleSeparatedDivorced Do you live alone? * Yes No Housemate Name: Are you a veteran? * - Select -YesNo Do you have a dog? * - Select -YesNo Do you have a cat? * - Select -YesNo Emergency Contact InformationMust have Emergency Contact First name: * Last name: * Phone number (home) * Phone number (mobile) * enter zero if no phone number Phone number (work) if any: * enter zero if no phone number Relationship to client: * Person completing application Who is completing this registration? * Client Other First name: Last name: Relationship to client: Phone number: Necessary Medical Information Primary Care Doctor: * Recent illness or accident: * Handicaps: * Cane Walker Wheelchair Oxygen None Other-Please specify Please specify: * Food Allergies * Yes No If yes list foods you are allergic to Potential Medication/Food Interaction? * Yes No If yes list medications you take with food interactions Do you have an illness or condition that made you change the kind of food you eat? * Yes No Do you eat fewer than 2 meals a day? * Yes No Do you eat few fruit and vegetables or milk products? * Yes No Do you eat alone most of the time? * Yes No Are there times that you do not always have enough money to buy the food you need? * Yes No Do you have tooth or mouth problems that make it hard for you to eat? * Yes No Do you take 3 or more different prescribed or over the counter drugs a day? * Yes No Have you lost or gained 10 pounds in the last 6 months without trying? * Yes No Are there times when you are not physically able to shop and/or cook? * Yes No Are you interested in the One Meal or Two Meal Option? * One Meal Two Meal Frozen Weekend Meals Please select One Meal (includes hot entree', vegetable, fruit, bread and milk) or Two Meal (includes the One Meal and sandwich and fruit). Client contribution will be determined based on sliding scale based on income. Contribution Determination Info Is your monthly income over $1,470.00? * Yes No Housing expense: Do you pay rent or mortgage? * Mortage Rent Own my Home If rent or mortgage enter monthly payment * Prescription expense: enter average amount of monthly out of pocket * How did you hear about us: - None -TelevisionNewspaperRadioSocial MediaNoticed meal delivery carsI VolunteerFamily and/or FriendDoctorAlways knew about Meals on WheelsOther: Please specify Other: Please specify Please Specify CAPTCHAThis question is for testing whether or not you are a human visitor and to prevent automated spam submissions.