I am applying... *

As a Client

On Behalf of a Client

If you are applying on behalf of the client, please provide the below information.

First Name

Last Name

Phone:

(###)

###

####

*

First Name

Last Name

Date of Birth: *

MM

DD

YYYY

Address: *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary Phone: *

(###)

###

####

Secondary Phone:

(###)

###

####

Accommodation : *

Choose one of the following options.

House

Basement Suite

Duplex/Fourplex

Townhouse

Apartment

Mobile Home

Other

Resides: *

Choose one of the following options.

Alone

With Spouse/Partner

With Family

Other

Medical Profile:

Check all that apply.

Medical condition requiring a modified diet

Mobility challenge

Hearing impairment

Sight impairment

Chewing/swallowing difficulty

Recent weight/appetite loss of concern

Food allergy or intolerance

Other diet modification requests (Non-preference)

Are you interested in Our Chef's Daily Special?

If so, please choose one of the following options.

Lunch and Supper

Lunch Only

Supper Only

Did you want to add breakfast to complete your nutrition for the day?

Yes

No

Are you interested in the My Choice Menu?

If so, please choose one of the following options.

Delivery

Pick-up

Schedule: *

Please tell us which days you would like to receive meal delivery (check all that apply)

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Desired Delivery Start Date: *

Please allow for 3 business days to process the application.

MM

DD

YYYY

Functioning Appliances: *

Check all that apply.

Fridge

Freezer

Oven

Microwave

If there is no answer (when we are delivering meals), what would you like us to do? *

Deliver to a Neighbour (Provide more details below)

Leave Meals in Cooler by Door (Not applicable for apartments)

Other (provide more details below)

May we contact the client for all matters relating to service? *

Please check one.

Yes

No

First Name

Last Name

Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary Phone:

(###)

###

####

Secondary Phone:

(###)

###

####

Same as: *

Client

Emergency Contact

Other

First Name

Last Name

Primary Phone:

(###)

###

####

Secondary Phone:

(###)

###

####

Please select one of the following options: *

I am applying for a reduction in cost based on my income (Available for the Our Chef's Daily Special service only). I will send My Notice of Assessment to signup@mealsonwheels.com or by fax to (403) 243-8438.

I will be paying the full cost for services ($14.25/day for Chef's Daily Special packages, or $7.50/day for one meal only) – or the flat cost noted on our menu (for My Choice Menu items).