MEALS ON WHEELS CLIENT APPLICATION - Hanover Area …
HANOVER AREA COUNCIL OF CHURCHES
136 CARLISLE ST. PO BOX 1561 HANOVER, PA 17331
PHONE: 717-633-6353 FAX: 717-633-6219
Email: adminhacc@
MEALS ON WHEELS CLIENT APPLICATION
NAME
_____________________________________________________________________________
(LAST) (FIRST) (MIDDLE INITIAL)
ADDRESS
_____________________________________________________________________________
(NUMBER & STREET) (APT./LOT NUMBER)
CITY ______________________ STATE ________ ZIP ______________
PHONE: _________________ DATE OF BIRTH ___________ SEX: M or F
(please circle)
START DATE: ___________________ END DATE: ________________
DAYS FOR DELIVERY: M T W TH F
(please circle)
PETS? Y or N DESCRIBE______________________________________________ (please circle)
ANY FOOD RESTRICTIONS/FOOD ALLERGIES: ______________________________
SPECIAL INSTRUCTIONS/DELIVERY INSTRUCTIONS: _______________________
_____________________________________________________________________________
Please circle all conditions that apply:
Alzheimer’s Cancer Dialysis Paralysis
Amputee Cataracts Emphysema Seizures
Arthritis Deafness Hard of Hearing Stroke
Asthma Dementia Heart Disease Vision Problem
Bed-Ridden Depression High Blood Pressure
Blindness Diabetes Lung Disease
Other: ______________________________________________________________________
Please circle any aids currently used:
Cane Glasses/Contacts Hearing Aid Oxygen
Pacemaker TTY/Phone Walker Wheelchair
Other: ______________________________________________________________________
Do you use a home health aide or home nurse service? Y or N
Do you receive help from other organization(s) Y or N
If so, which one(s)?
_____________________________________________________________________________
NAME:_________________________________________
ADDRESS: _____________________________________
City, State, Zip: __________________________________
Phone: __________________ Fax: _________________
I authorize the release of my medical condition and other information to and among agencies and their agents necessary to determine appropriate services for my care. I understand that I may revoke this release of information in writing.
Person completing application: ______________________________________________
(signature)
Date: ________________ ______________________________________________
Relationship to client (if other than client)
Client Name: ____________________________ Date of Birth: ________________
Address: ____________________________
City, State, Zip __________________________
REFERRING AGENCY: ___________________________
Address: _________________________________________
City, State, Zip ____________________________________
Phone: ________________ Fax: ______________ Email: ______________________
Signature: ________________________________
(must be hand signed/ No signature stamp please)
Title: _____________________________________
Vision: _____________ Walking: _______________ Hearing: __________________
Mental Capacity: ____________________ Other: _____________________________
Length of time to receive Meals on Wheels: ________________________
1. Name: ______________________________________
Address: ____________________________________
City, State, Zip: ______________________________
Home Phone: ________________ Work Phone: _____________ Cell Phone: _________
Email Address: _________________________________________
Relationship to Client ___________________________________
Does this person have a key to the client’s home or apartment? Y or N
2. Name: ______________________________________
Address: ____________________________________
City, State, Zip: ______________________________
Home Phone: ________________ Work Phone: _____________ Cell Phone: _________
Email Address: _________________________________________
Relationship to Client ___________________________________
Does this person have a key to the client’s home or apartment? Y or N
_____________________________________________________________________________
HANOVER AREA COUNCIL OF CHURCHES
136 CARLISLE ST. PO BOX 1561 HANOVER, PA 17331
PHONE: 717-633-6353 FAX: 717-633-6219
Email: adminhacc@
-----------------------
CLIENT INFORMATION
DELIVERY INFORMATION
MEDICAL INFORMATION
OTHER INFORMATION
PHYSICIAN INFORMATION
MEALS ON WHEELS
REFERRAL FOR SERVICE
Referral is required by Clergy, Visiting Nurse Association, Hospital, Physician, or other Social Service Agency. Please submit this form to one of these listed for completion and mail with application to Hanover Area Council of Churches, PO Box 1561 Hanover, PA 17331 or email to adminhacc@
REFERRING AGENCY INFORMATION
EMERGENCY CONTACT INFORMATION
(must be reachable during mealtime)
2 contact persons are required
................
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