Meals on Wheels Client Application

Home Delivered Meals

* Required

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
Date*
MM slash DD slash YYYY
Client Information
First Name*
Last Name*
AKA
Street Address*
City*
ZIP Code*
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
Home Phone*
Cell Phone
Email Address
SS# (last 4 digits only)
Date of Birth*
MM slash DD slash YYYY
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
- No
Lives Alone*
- Yes
- No
Veteran*
- Yes
- No
Spanish Speaker Only
- Yes
- No
Receives SSI*
- Yes
- No
Receives MediCal*
- Yes
- No
Are You Disabled?*
- Yes
- No
Marital Status*
Race or Ethnicity*
On Special Diet?
Communication Barrier, if any?
CAPTCHA
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
Click the SEND button only once. It may take a few seconds for the form to be submitted. You will see a confirmation message when the form has been received.
Email
This field is for validation purposes and should be left unchanged.