Welcome to our Meal Sign-Up page. This application will take approximately 5-8 minutes to complete. This page is for PAY CLIENTS ONLY. If you require a free or reduced cost meal, please contact us at (505) 823-8082 to request an application for our LIFE program.

NOTE:
*After submission, a client services representative will call you in 1-2 business days to collect payment information
*A $25 non-refundable administrative fee is required prior to starting service
*Deposits can be made with credit card, debit card, or electronic check



MaleFemale







Yes



YesNo



EnglishSpanish


CaucasianAfrican AmericanHispanicNative AmericanAsian/Pacific IslanderOther


YesNo



VeteranNot a VeteranSpouse of a VeteranDon't Know or N/A



RegularHeart HealthyDiabeticRenalVegetarianPre-CutMechanically SoftenedPureed


EggsNutsCitrusCoconutChileDark GreensFishPork


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MilkNo Milk


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Not ApplicableMondayTuesdayWednesdayThursdayFriday


Add breakfastAdd dinner


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Yes

NAPIS Assessment: The following two assessments help us measure how well the client can perform basic daily activities as well as the client's eating habits. We use this information for writing and reporting on various grants. Please answer the questions on behalf of the client. Answers to these questions will not effect eligibility for any programs.


Independent (Without Help)Assisted (With Help)Dependent (Can't Do)Refuse to Answer


Independent (Without Help)Assisted (With Help)Dependent (Can't Do)Refuse to Answer


Independent (Without Help)Assisted (With Help)Dependent (Can't Do)Refuse to Answer


Independent (Without Help)Assisted (With Help)Dependent (Can't Do)Refuse to Answer


Independent (Without Help)Assisted (With Help)Dependent (Can't Do)Refuse to Answer


Independent (Without Help)Assisted (With Help)Dependent (Can't Do)Refuse to Answer


Independent (Without Help)Assisted (With Help)Dependent (Can't Do)Refuse to Answer


Independent (Without Help)Assisted (With Help)Dependent (Can't Do)Refuse to Answer


Independent (Without Help)Assisted (With Help)Dependent (Can't Do)Refuse to Answer


Independent (Without Help)Assisted (With Help)Dependent (Can't Do)Refuse to Answer


YesNoRefuse to Answer


YesNoRefuse to Answer


YesNoRefuse to Answer


YesNoRefuse to Answer


YesNoRefuse to Answer


YesNoRefuse to Answer


YesNoRefuse to Answer


YesNoRefuse to Answer


YesNoRefuse to Answer


YesNoRefuse to Answer


YesNoRefuse to Answer


YesNoRefuse to Answer


YesNoRefuse to Answer


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