Meals on Wheels Client Application

Thank you for your interest in receiving meals from Meals on Wheels for Santa Cruz County! We provide meals to more than 1,300 seniors throughout Santa Cruz County each year.

If you do not live in Santa Cruz County or are applying for someone who does not live in Santa Cruz County, please visit the Meals on Wheels America directory and search for your local provider: mealsonwheelsamerica.org/find-meals

Meals on Wheels for Santa Cruz County serves only those aged 60 and older. If you are under 60, please visit cdss.ca.gov/food-banks for food assistance or communitybridges.org/frc/ for additional services.

Please complete one application for each person who is applying.

Date*

Are you 60 or older?*

Yes

Client Information

First Name*

Last Name*

AKA

Street Address*

City*

ZIP Code*

Home Phone*

Cell Phone

Email Address

SS# (last 4 digits only)

Date of Birth*

Emergency Contact Information

Emergency Contact

Relationship

Home Phone

Cell Phone

Street Address

City

State

ZIP Code

Emergency Contact

Relationship

Home Phone

Cell Phone

Street Address

City

State

ZIP Code

Referral Information (Optional)

Doctor Name

Doctor Phone

Referral Name/Agency

Referral Phone

Demographic Data

Gender*

Male

Female

Low Income*

Yes

Lives Alone*

Yes

Veteran*

Yes

Spanish Speaker Only

Yes

Receives SSI*

Yes

Receives MediCal*

Yes

Are You Disabled?*

Yes

Marital Status*

Race or Ethnicity*

On Special Diet?

Communication Barrier, if any?

CAPTCHA

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Comments

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Meals on Wheels Client Application

Home Delivered Meals

Client Information

Emergency Contact Information

Referral Information (Optional)

Demographic Data