Client Application

Thank you for your interest in Meals on Wheels Fort Collins!

Please complete, sign, and return the Client Enrollment Form below.

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. Please give us 48 business hours to process the application once we have received all required documentation.

 

Please call our office if you have any questions at 970-484-6325.

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.
Are you filling this app for:
General Information
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. Email your verification to info@fcmow.org.
Gender
Are you a Veteran?
Are you Hispanic or Latino?
Race/Ethnicity
Head of Household (responsible for minor children)
Would you like to be considered for a reduced fee?
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 include a copy with your application. Email your verification to info@fcmow.org.
Have you ever received Meals on Wheels before?
Meal Information
Meal Type:
Delivery Schedule
Number of Meals per delivery
Are you able to answer the door?
Do you have pets?
Emergency Contact Information
Emergency Contact 1
Emergency Contact 2
Social or Case Worker
Do you have one of the following working with you?
Billing Information
Would you like your bill mailed to you?
Would you like your bill emailed to you?
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.
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.
Meal cancellations or additions must be called in no later than 1:00 pm TWO business days prior to the delivery
You can call our office 24 hours a day and leave a message with your name
Meal delivery is normally between 11:30 and 12:45. Please note that weather, traffic, etc. may affect delivery time.
Meals on Wheels utilizes volunteer drivers to deliver your meals. These individuals are not trained in home health care so are not able to assist in any medically-based tasks including dressing, movement of clients, etc.
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 )

**REMEMBER TO SEND ALL SUPPORTING DOCUMENTS WITH COMPLETED APPLICATION. This includes the FRONT & BACK of your ID as well as your income verification (if you are seeking a reduced fee)**

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.

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.

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