First Name: Last Name: Phone Number: Email Address: Mailing Address: City: State: - Select -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 Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Marianas Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Zip Code: How did you find out about Meals on Wheels? (check as many as apply) - Select -Internet Radio TV Newspaper Care Giver Insurance Friend or Family Member Other Date of Birth: Handicapped: - Select -Yes No Do you live alone? - Select -Yes No Are you able to open the door? - Select -Yes No Do you have any known food allergies? - Select -Yes No If yes, what are they? Are you a diabetic? - Select -Yes No Any comments/questions? I want meals on (check all that apply) Monday Tuesday Wednesday Thursday Friday Beverage: I prefer (check one) - Select -Milk Juice No beverage Would you also like 2 frozen meals each week (for the weekends)? - Select -Yes No Emergency Contact Name: Emergency Contact Phone: Method of payment (check one): - Select -Self Pay Long Term Care Insurance Other If other, please explain: (security question) What color is the sky? CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Submit
