Complete the form below to apply for services through MOW Wake County 1 Start 2 Page break 3 Preview 4 Complete PROGRAM TYPE Which program type are you interested in? Check all that apply. * Self Pay - $4.75 per meal and route availability Waiting List, No charge for meals, must meet qualifications and route availability Hospital to Home, Must be referred by a Medical Provider, exclusively for individuals recently released from a hospital or rehabilitation center. (Meals provided for 10 days) CLIENT INFORMATION First Name * Last Name * Address (Street) * Apartment Number and Apartment Name City * State - None -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code * Client Telephone Number * Client Secondary Telephone Number Last 4 digits of SSN * Client birthdate * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year1900190119021903190419051906190719081909191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050 Sex * Race * Homeowner * Yes No MARITAL STATUS What is your current marital status? Single - Never Married Married Divorced Widowed HOUSEHOLD INFORMATION Do you live alone? * Yes No 2 in home * Yes No 3 or more in home * Yes No Group/Shared home * Yes No Monthly Income * Homebound * Yes No Do you have pets in the home? * Yes No Dog Yes No Cat Yes No Are you a veteran? * Yes No List other agencies that are serving the client * REFERRAL INFORMATION Referred By * Telephone Number * Email Referral Agency Client Relationship * EMERGENCY CONTACT INFO Emergency Contact Name * Emergency Contact Relationship * Emergency Contact Primary Telephone Number * Emergency Contact Name * Emergency Contact Relationship * Emergency Contact Primary Telephone Number * CONGREGATE SITESMeals on Wheels Wake County serves a daily lunch at noon, Monday through Friday, at congregate dining rooms located throughout the area.Please review list of congregate sites here: https://www.wakemow.org/congregate-dining-rooms Can you drive to a senior congregate site to eat meals Monday through Friday? * Yes No Do you have someone who can drive you to a congregate site? Yes No CAPTCHAThis question is for testing whether or not you are a human visitor and to prevent automated spam submissions.