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623.594.9588

Application for Meal Service

Please complete the form below. Alternatively, you can download the PDF version, complete it, and return to our office.

Your information

First name *

Last *

Address *

City *

State *

ZIP *

Gate code

Email *

Preferred phone *

Type *

Home

Cell

Alternative phone

Type

Home

Cell

Birth month *

Birth day *

Birth year *

Gender *

Male

Female

Marital status *

Single

Married

Widowed

Other

Add another person? *

Yes

First name *

Last name *

Birth month

Birth day

Birth year

Gender

Male

Female

How did you hear about Meals of Joy? *

Emergency contact information

Contact name *

Phone *

Relationship to you *

Address *

City *

State *

ZIP *

Special Medical Information

Is there any special medical condition or issue we should be aware of when delivering meals?

Do you have any food allergies?

Service Information

What date would you like meal service to start? *

Days of the week you would like to receive meals (please check preferences) *

Monday

Tuesday

Wednesday

Thursday

Friday

Varies

If receiving meals on a set schedule, do you want to be set up on a recurring basis? *

Yes

Income and Other Demographic Information

Please select your household income *

$1000 per month or less

$1,001 per month or more

(Information used by Meals of Joy when applying for grants. Specific amounts not needed)

How many people reside in your household? *

Please check any which apply *

I, or my spouse (if married) is a Veteran of the United States military

I have someone who usually assists you with the daily tasks of living

I have to use an assistive devise such as a cane, walker or wheelchair

I am a year round resident of Arizona?

Authorization & Acknowledgement

Name of person completing this form

Relationship to you

Signature *

For legal purposes, typing your name is considered the same as signing

Date

Message

501 East Plaza Circle, #15, Litchfield Park, AZ 85340

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