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Home Meal Delivery & More

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Apply for Program

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

Day

Year

Gender *

Male

Female

Other

Veteran Status *

Veteran

Veteran Dependent

Not a Veteran

Date for meals to start (Your service will begin on the nearest subsequent Monday or Wednesday) *

Month

Day

Year

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 ($5/day)

Cold Meals ($4/day)

Both Meals - one hot and one cold meal ($7/day)

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)

Drink *

Milk

Juice

Food Allergies *

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:

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