Welcome to our Meal Sign-Up page. This application will take approximately 5-8 minutes to complete. This page is for private 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 10 meal deposit is required prior to starting service (HOT meals $69.50; FROZEN meals$59.50)
*Deposits can be made with credit card, debit card, or electronic check
*All deposits are non-refundable









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MaleFemale


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


CaucasianAfrican AmericanHispanicNative AmericanAsian/Pacific IslanderOther


EnglishSpanish


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RegularHeart HealthyDiabeticRenalVegetarianPre-CutMechanically SoftenedPureed


EggsNutsCitrusCoconutChileDark GreensFishPork


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MilkNo Milk


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Add breakfastAdd dinner


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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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