Sign Up Step 1 of 8 12% Our programs are based in the Minneapolis/St. Paul metro area. If you’re looking for a program in another area, visit mealsonwheelsamerica.org.Street Address*Apartment NumberCity*State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip Code*indistrictThis is a HIDDEN field. DO NOT EDIT THIS OR FORM WILL NOT WORKCheck Address We deliver to this address!Would you like to fill out your application online or continue via phone?*Continue OnlineContinue Via PhonePlease choose one of the following*I am a care professional or agency enrolling a client through a government-funded programI am a caregiver, meals are for myself, a loved one, or family member (self-pay)Are these meals for you?*YesNoRequestor InformationAs the person completing this form, please tell us a little bit about yourself:Name* First Last Email Daytime Phone Number*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code What is your relationship to the person who will receive meals?* Referrer InformationPlease enter the following information about yourself.Referrer Name*Agency*Daytime Phone Number*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Meal Recipient InformationOur clients' privacy is important to us. Please take a minute to review our Notice of Privacy Practices before continuing.Name* First Middle Initial Last Daytime Phone Number*Email Date of Birth* MM DD YYYY Metro Meals on Wheels does not discriminate on the basis of gender identity or race. We use gender and race data to track the effectiveness of our program. Your answers to the following questions will not affect your ability to receive services.Gender*FemaleMaleOtherPrefer not to answerRace/Ethnicity* White Black or African American Latino or Hispanic Asian American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Other Prefer not to answer Billing InformationMeals are priced affordably and based on your ability to pay. We will follow up with you after you submit this form to discuss payment options. Call us at 612-623-3363 with any questions.Billing address*Billing address is my addressBilling address is the home address of the person receiving mealsEnter another billing addressBilling address*Billing address is my addressEnter another billing addressName First Last Billing Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Daytime Phone Number*Email addressWaiver InformationPayer*MN MedicaidBlue Plus (Bridgeview)Health PartnersMedicaUCareWaiver*Alternative Care ProgramBrain Injury (BI)Community Access for DisabilityInclusion (CADI)Developmental Disabilities Waiver (DD)Elderly Waiver (EW)Essential Community Supports Program (ECS)MN Medicaid PMI #*Payer ID #Does the client have a Spenddown or Waiver Obligation?*YesNoHow much is the Spenddown or Waiver Obligation?*Service Agreement/Authorization Requested?*YesNoNumber of units/meals per week client is authorized to receive:*1234567Comments Meal InformationRequested Start Date* We can generally begin service within 3 business days of receiving a completed application.I would like to receive meals on the following days:* Monday Tuesday Wednesday Thursday Friday Saturday (delivered during the week for reheating) Sunday (delivered during the week for reheating) Dietary needs and preferencesSelect all that apply. Vegetarian Gluten free Lactose free Renal Diabetic-friendly Low-sodium Mechanical Soft Pureed Other Please list any other dietary needs and/or preferencesNote: We offer cultural meal options including Kosher, Halal and authentic Asian cuisine, in certain areas. Please call 612-623-3363 to ask about availability.Beverage choice*MilkJuiceFood AllergiesPlease list any food allergies, if applicable.Delivery InstructionsPlease deliver meals to*Front DoorSide DoorBack DoorWhat should the driver do upon arrival?*KnockRing BellBuzz ApartmentApartment CodeIf applicable.Other special delivery instructions (optional)Other InformationDoes the person receiving meals live alone?*YesNoWith whom do they live?Does the person receiving meals have any pets?*YesNoPlease list the type(s) of pets Health InformationWhat is your reason for requesting Meals on Wheels?*Health Issues* Diabetes Hypertension Dementia Vision Loss Hearing Loss Arthritis Cancer Mental/Emotional Disability Uses Walker/Cane/Wheelchair None Other Other Health Issues*Medical InformationReason/Cause for needing meals*Physician's nameClinic namePhysician's phone #Preferred hospitalHealth Issues* Diabetes Hypertension Dementia Vision Loss Hearing Loss Arthritis Cancer Mental/Emotional Disability Uses Walker/Cane/Wheelchair None Other Other Health Issues* Emergency Contact InformationName* First Last Relationship to Recipient*Primary Phone Number*Alternate Phone NumberDoes the person listed live in the Minneapolis/St. Paul metro area?*YesNo This iframe contains the logic required to handle Ajax powered Gravity Forms.
