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About
Home
Meals on Wheels
Daily Meals
About
Friendly Visitors
How It Works
About
Volunteer
In The News
Contact
Donate
La Jolla Meals On Wheels Client Application
Fields marked with an * are required
Name
*
First Name
Last Name
Address
*
City
*
State
*
Zip/Postal Code
*
Phone
*
(###)
###
####
Email
Date of Birth
*
MM
DD
YYYY
Requested date to start service
Estimated duration of service
Sex
Male
Female
Housing Type
House
Apartment
Does anyone live with you
Yes
No
If yes, name
Type of drink required
Milk
Juice
Water
How did you hear about us?
Emergency Contact Information
Name of Emergency Contact
Address of Emergency Contact
Phone number of Emergency Contact
(###)
###
####
Relationship to you
Additional Emergency Contact - optional
Name, phone number and relationship of additional emergency contact
APPLICATION/AGREEMENT STATEMENT
1. I would like to apply for Meals-on-Wheels. I understand that the cost will be $7.50 per day for one hot meal and one cold meal; 2. The meals will be delivered to my door on a daily basis - Monday through Friday, including holidays; 3. I will give at least 2 business days’ notice if I wish to cancel the Meals-on-Wheels program; 4. Except in the case of medical emergencies, if I need delivery stopped for one day, I will call the office at least 2 business days in advance.
I agree to the above provisions.
*
How did you hear about us?
*
Thank you for your submission!
We will contact you within two business days.
