La Jolla Meals On Wheels Client Application

Fields marked with an * are required

Name *
Name
Phone *
Phone
Date of Birth *
Date of Birth
Sex
Housing Type
Does anyone live with you
Type of drink required
Emergency Contact Information
Phone number of Emergency Contact
Phone number of Emergency Contact
Additional Emergency Contact - optional
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. *