Please complete this form to apply for Meals on Wheels in Terre Haute. We will contact you soon. In the meantime, you can also submit payment for meals online. Name of person completing this form: * Relationship to meal recipient * I am the meal recipient I am a relative other If you are not the meal recipient or a listed emergency contact, please provide your contact info here: * Meal Recipient First Name * Last Name * Street Address * City, State Zip Code * Phone Number * Date of Birth * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020 Gender * Male Female Other Ethnicity * Caucasian Asian American Indian Black Hispanic Other Veteran Status * Veteran Veteran Dependent Not a Veteran Date for meals to start * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20172018201920202021 We like to get 2 weeks of payments to begin meal service. How do you wish to pay? Once you submit this form, you will be redirected to a payment page to pay for meals if you chose that option. Thank you. Payment Options * I will pay online after I submit this form I will mail a payment to Meals on Wheels TH Please call me to discuss other payment options Meal Options * Hot Meals ($4/day) Cold Meals ($2.50/day) Both Meals - one hot and one cold meal ($5.50/day) Indicate which days for meal delivery * Monday Tuesday Wednesday Thursday Friday Friday Option * 1 Meal for Friday 2 Meals for Friday (use the extra meal on the weekend) 3 Meals for Friday (use the extra meals on the weekend) Type of diet (ex. diabetic, low sodium, low cholesterol, etc.) * Drink * Milk Juice Dietary Exceptions (allergies, preferences, etc.) * Emergency Contact First Name of Contact * Last Name of Contact * Email Address * Street Address * City, State Zip Code * Phone Number * Alternate Phone Relationship to Recipient * Primary Care Physician * Phone Number for Physician * Reason for applying * Pets? * Delivery Instructions Delivery Instructions: Type any special instructions here (such as deliver in the back door, etc) CAPTCHAThis question is for testing whether or not you are a human visitor and to prevent automated spam submissions.