Fort Dodge Community Foundation

Application for Service Meals on Wheels

Is this an Apartment complex? Yes No

Who should we contact regarding this application?

Are you homebound? Yes No

Are you unable to prepare your own meals? Yes No

Do you have medical, mobility, hearing, vision or communication issues we should know about? Yes No

Does anyone else live in the home with you? Yes No

General directions to home

Where should meal be delivered? (backdoor, front, side door, inside porch)

EMERGENCY CONTACTS

Local Residents who can check on client in an emergency who are not living in the same residence – day time phone numbers are required

Emergency Contact 1

Are they local? Yes No

Emergency Contact 2

Are they local? Yes No

FAMILY CONTACT IF EMERGENCY CONTACT IS NOT A FAMILY MEMBER

Are they local? Yes No

MONTHLY INCOME INFORMATION

Pay full amount of $6.00 per week, no financial disclosure required
Yes No

Client Income

Includes Social Security, Pensions, Dividends, Interest etc.

Client Expenses

Housing Expenses: Rent, Mortgage, Taxes, Insurance

Utilities Expenses: Gas, Electric, Water

Medical Expenses: Doctors, Medicine, Home Nursing Care Insurance Premiums, Depends etc.

Please clarify Other Expenses:

PAYMENT

Person Responsible for paying the bill:

Please indicate preferred number

REFERRAL INFORMATION

How did you hear about Meals on Wheels?

Do you have a social worker or case manager assisting you from another agency? Yes No

I verify that the information I have provided is accurate. According to the sliding fee schedule, I agree to pay for each meal received. I understand that my fee status will be re-evaluated annually. I realize that if this statement is not completed and returned to the Meals on Wheels Office, I will be required to pay the full fee of $ per meal.

Signed (Family Member or Designee if client cannot sign)

Application for Service Meals on Wheels

SERVICE ELIGIBILITY

EMERGENCY CONTACTS

FAMILY CONTACT IF EMERGENCY CONTACT IS NOT A FAMILY MEMBER

MONTHLY INCOME INFORMATION

Client Income

Client Expenses

PAYMENT

REFERRAL INFORMATION