Lake City Senior Days Meal Delivery Enrollment Form
Hunger Intervention Program can deliver the same freshly made meals that are served at the Lake City Community Center to your home. These meals are delivered between 11am-1pm on Mondays, Wednesdays, and Fridays. Currently, we are prioritizing this service for residents of the zip codes 98125, 98155, 98133, but will take on additional participants as we are able. We can only serve a limited number of participants in this way, so please accurately fill out the information below so that we can best serve those who are in greatest need of delivered meals. For households with multiple interested participants, please fill out one application per participant.
This form and all the information captured within will be kept confidential. This information will not be shared beyond the Lake City Seniors collaborative team. The purpose of collecting this information is to ensure that meal delivery resources are allocated in the most equitable manner possible.
Name *
Your answer
Date of Birth *
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DD
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Email Address (Not Required)
Your answer
Phone Number *
Your answer
Address *
Your answer
Food Allergies
Your answer
How many meals a day would you like to receive? *
Will you be able to receive meals, at the address provided above, every Monday, Wednesday, and Friday between 11am – 1pm?
Would you like vegetarian meals? *
Are you currently receiving other meal delivery services (example: Meals on Wheels)? *
Would you like to receive in-person check-ins from our social worker?
Do you utilize part-time/full-time home care assistance (home attendant, housekeeping, nurse) to assist with activities of daily living? *
Are you able to leave your home without outside assistance? *
Do you struggle to prepare meals for yourself for any reason (example: apartment doesn’t have a kitchen, lack of physical strength to shop or prepare meals, lack of meal prep knowledge, or any other reason)?
Any additional information
Your answer
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