Apply for Program | Terre Haute Area Meals on Wheels

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

If you are not the meal recipient or a listed emergency contact, please provide your contact info here:

First Name

Last Name

Street Address

City, State Zip Code

Phone Number

Date of Birth

Gender

Ethnicity

Veteran Status

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

Payment Options

Meal Options

Indicate which days for meal delivery

Friday Option

Drink

Food Allergies

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: