Client Application | Meals on Wheels Fort Collins

Who should we contact to perform the intake phone call? Please provide name, relationship to client and phone number.

General Information

Applicant's Name:

Address

Apartment/Unit #:

City, State,

Zip

Applicant's Birthdate

CLIENTS UNDER THE AGE OF 62 MUST HAVE A MEDICAL CONDITION PREVENTING THE ABILITY TO PREPARE MEALS AND BE HOMEBOUND. MEDICAL VERIFICATION MUST BE INCLUDED WITH YOUR APPLICATION. Attach at the end of the application, or email your verification to info@fcmow.org.

Email address

Applicant's Phone Number:

Gender

Male

Female

Prefer not to answer

Are you a Veteran?

Yes

No

Preferred Pronouns (if applicable):

Are you Hispanic or Latino?

Yes

No

Prefer not to answer

Household Size

Head of Household (responsible for minor children)

Yes

No

Please provide gross monthly household income (before taxes)

Would you like to be considered for a reduced fee?

Yes

No

If you would like to be considered for a reduced fee, we require documentation of your gross monthly income (such as a bank statement, direct deposit info, social security statement, etc). Please attach a copy at the end of the application, or email it to info@fcmow.org.

Have you ever received Meals on Wheels before?

Yes

No

How did you hear about Meals on Wheels?

Why are you seeking our services?

Meal Information

Meal Type:

Regular

Large Regular

Vegetarian

Dental Soft

Pureed

Delivery Schedule

Monday

Tuesday

Wednesday

Thursday

Friday

Number of Meals per delivery

1

2

Are you able to answer the door?

Yes

No

Do you have pets?

Yes

No

If yes, what kind and the name of your pet

Special Delivery Instructions (hard of hearing, uses walker, etc)

Emergency Contact Information

Emergency Contact 1

Contact #1 Name

Relationship to client:

Address

Apartment/Unit #:

Phone Number

Email

Emergency Contact 2

Contact #2 Name

Relationship to client:

Address

Apartment/Unit #:

Phone Number

Email

Billing Information

Would you like your bill mailed to you?

Yes

No

Billing Information (If different from applicant). Please include name, address, and phone number

Apartment/Unit #:

Would you like your bill emailed to you?

Yes

No

Email Address:

PLEASE CHECK THAT YOU HAVE READ AND UNDERSTAND THE FOLLOWING

I understand that Poudre Valley Hospital's Kitchen cannot accommodate allergy requests and may not be able to meet my dietary needs.

Yes

If you will not be home at time of delivery, please call the office to let us know you will not be home and leave a cooler outside for your meal. If you receive a message from us, please call us to let us know you have received your meal and are ok. If we do not hear from you and cannot reach you, we will attempt to contact your emergency contact(s) or contact the non-emergency police to do a wellness check, if necessary.

Yes

Meal cancellations or additions must be called in no later than 1:00 pm TWO business days prior to the delivery.

Yes

You can call our office 24 hours a day and leave a message with your name.

Yes

Meal delivery is normally between 11:30 and 12:45. Please note that weather, traffic, etc. may affect delivery time.

Yes

Meals on Wheels utilizes volunteer drivers to deliver your meals. These individuals are not trained in home health care and are unable to assist in any medically-based tasks including dressing, movement of clients, etc.

Yes

I hereby grant and convey unto Meals on Wheels for Fort Collins, CO, Inc., all rights, title and interest in any and all photographs, video or audio recordings of or including my image or voice, used in any publications, news releases, online and in other communications related to the mission of Meals on Wheels for Fort Collins. (optional )

Yes

No

Signature

**PLEASE REMEMBER TO SEND IN ALL SUPPORTING DOCUMENTS WITH COMPLETED APPLICATION. This includes a copy of your PHOTO ID, income verification if requesting a reduced fee, and medical verification if under the age of 62. If you do not have documents ready at this time, they can be emailed to info@fcmow.org**

Once we have received your completed enrollment form and all required documentation, we will call phone number on application to do an intake call and confirm start date. If you have not heard from our office within 48 hours, please call 970-484-6325.

*PLEASE NOTE WE ARE EXPERIENCING A HIGH VOLUME OF APPLICATIONS AT THIS TIME. IT MAY TAKE LONG THAN THE 48 HOURS TO GET IN TOUCH.

Meals on Wheels for Fort Collins does not discriminate on the grounds of race, color, national origin, religion, creed, disability, age, sex, actual or perceived sexual orientation, gender identity, marital status, familial status, or because a family includes children.

Meals on Wheels for Fort Collins encourages reporting of all perceived incidents of discrimination or harassment. It is the policy of Meals of Wheels for Fort Collins to promptly and thoroughly investigate such reports. Meals on Wheels for Fort Collins prohibits retaliation against any individual who reports discrimination or harassment or participates in an investigation of such reports. Any client with a concern should submit a written complaint to the Executive Director. The Executive Director will work with the client to resolve the concern in a fair and equitable manner. If the matter is not resolved then the client may appeal to the Board President. The client will receive a written response regarding the board's decision.

(security question) What color is the sky?