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*This field is hidden when viewing the formindistrictThis is a HIDDEN field. DO NOT EDIT THIS OR FORM WILL NOT WORKCheck AddressWe're sorry, we do not currently offer meal delivery to your area. Please visit mealsonwheelsamerica.org to find a program in your area. We deliver to this address!Would you like to fill out your application online or continue via phone?* Continue Online Continue Via Phone Please choose one of the following* I am a care professional or agency enrolling a client through a government-funded program I am a caregiver, meals are for myself, a loved one, or family member Are these meals for you?* Yes No Requestor InformationAs the person completing this form, please tell us a little bit about yourself:Name* Name Last Email Daytime Phone Number*Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest 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* Name Middle Initial Last Daytime Phone Number*Email Date of Birth* Month Day Year 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 East African Latino or Hispanic Asian American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Other Prefer not to answer Primary language spoken* English Spanish Somali Your answer will help guide our communication with the meal recipient.Is the person receiving meals a Veteran? Yes No 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 address Billing address is the home address of the person receiving meals Enter another billing address Billing address* Billing address is my address Enter another billing address Name Name Last Billing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Daytime Phone Number*Email addressWaiver InformationPayer*MN MedicaidBlue Plus (Bridgeview)Health PartnersMedicaUCareCOVID-19 Relief ProgramWaiver*Alternative Care ProgramBrain Injury (BI)Community Access for DisabilityInclusion (CADI)Developmental Disabilities Waiver (DD)Elderly Waiver (EW)Essential Community Supports Program (ECS)DCM Grant-Short Term ServicesCOVID-19 ReliefMN Medicaid PMI # (does not apply to COVID-19 Relief)Payer ID# (Bridgeview, Health Partners, Medica, UCare - does not apply to COVID-19 Relief)This field is hidden when viewing the formI am enrolling a new client through a waivered service and would like information about additional COVID-19 relief meals beyond those authorized by the waiver. Up to 21 meals a week may be available. Yes No Does the client have a Spenddown or Waiver Obligation?* Yes No How 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* MM slash DD slash YYYY 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) 5 frozen meals delivered once weekly 7 frozen meals delivered once weekly Cultural meal optionsPlease select if you adhere to one of the following diets. Kosher Halal 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 preferencesBeverage choice* Milk Juice No beverage Food AllergiesPlease list any food allergies, if applicable.Delivery InstructionsPlease deliver meals to* Front Door Side Door Back Door What should the driver do upon arrival?* Knock Ring Bell Buzz Apartment Apartment CodeIf applicable.Other special delivery instructions (optional)Other InformationDoes the person receiving meals live alone?* Yes No With whom do they live?Does the person receiving meals have any pets?* Yes No Please list the type(s) of pets Health InformationWhat is your reason for requesting Meals on Wheels?*Are you requesting meals due to hardship caused by the COVID-19 Pandemic? Financial assistance is available to those age 50+.* Yes No 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* Name Last Relationship to Recipient*Primary Phone Number*Alternate Phone NumberDoes the person listed live in the Minneapolis/St. Paul metro area?* Yes No
