Apply for Meals

SIGN-UP FORM

Welcome to our Meal Sign-Up page. The application will take approximately 5-7 minutes to complete.

NOTE:
*After submission, a client services representative will call you to discuss the program and finalize your application. Please know there may be a registration fee associated with your application. Calls are made in the order in which applications are received.

Application for Meal Service

Meal Service
Are you completing this application on behalf of someone else? If NO (you are the client), please skip to "Client Information" section below.
If you are not the client, please provide your name
If you are not the client, please provide your name
First
Last
Who should we contact to ask questions about this application?
CLIENT INFORMATION
Client Name (Required)
Client Name (Required)
First
Last
Address
Address
City
State/Province
Zip/Postal
Is this a home or cell phone?
Client Gender Identity (Required; Check all that apply)
Will the client need an interpreter?
Client Race and Ethnicity
Client Veteran Status (Required)
Does the client have any pets?
We have partnered with Long Leash on Life and other generous donors to offer clients complimentary pet food, veterinary visits, dog walking, and more. Would the client like to sign up to receive complimentary pet food and other pet wellness opportunities?
EMERGENCY CONTACT INFORMATION
Emergency Contact Name (Required)
Emergency Contact Name (Required)
First
Last
Does the client live with the Emergency Contact? (Required)
Does the client identify as having a disability?
BILLING INFORMATION
Bill to Name (Required)
Bill to Name (Required)
First
Last
Bill to Address
Bill to Address
City
State/Province
Zip/Postal
Country
Type of Diet Needed
Food Allergies (Although we try to accommodate all requests, we do not make guarantees)
Please select the amount of HOT LUNCH meals you would like delivered on:
Monday
Tuesday
Wednesday
Thursday
Friday
Would you like to receive milk with your hot lunch meals? (Your choice will not effect the cost of your meals)
Please select the number of FROZEN LUNCH meals you would like to receive each week
Frozen meals are delivered in bulk, one day per week. What day you would like to receive your FROZEN LUNCH meals?
In addition to the lunch meal we offer, we also offer a smaller, chilled or shelf stable breakfast and dinner (sandwich plus a side) Breakfast/Dinners are $3.70 each and are available with your hot lunch. Would you like to add breakfast and/or dinner to your hot lunch meals? If yes, please check below.
We have partnered with the ABQ Journal to offer all our clients a FREE copy of the Journal with their meal delivery. Would the client like to receive the ABQ Journal newspaper with their meal?
We have partnered with Roadrunner Food Bank and Silver Horizons to offer clients monthly bags of shelf stable foods. Weekend Pantry Bags may not be appropriate for all diet types. Would the client like to receive a monthly pantry bag?
Would you like to sign up to receive an emergency meal in case of winter weather closure? (Emergency meals will be delivered in Nov/Dec each year. There is no additional charge for this emergency meal)
Delivery Acknowledgement (Required): Do you understand that the client or another person MUST be home to receive delivery between the hours of 10:00am - 2:00pm. Meals on Wheels will not leave a meal unattended at your door. Failure to be home without prior notification may result in removal from the program.
Wellness Check Acknowledgement (Required): Do you understand that Meals on Wheels may call a Wellness Check with APD on your behalf if if we are unable to reach you or your emergency contact for a missed delivery?
Help save paper! Use my email to send invoices.
Client Wellbeing Questions. Please answer these questions to the best of your knowledge. Answers to these questions assist us on grant applications and other reports. All data is combined with other respondents and no personally identifiable information is used when reporting.
Other than a regular check-up or follow-up, how many times in the past three (3) months did you have to go to the doctor? (Example: visiting a doctor for an emergency or new illness)
In the past three (3) months, how often did you have to choose between paying a bill (rent, utilities, car, buying medicine, etc.) or buying food?
In the past three (3) months, have you fallen in your home?
In the past three (3) months, how often have you felt depressed or very sad?