AMOR Healing Kitchen Client Application
Please fill out the following application to the best of your ability and submit once you are done.
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Email *
Today's date *
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AMOR Healing Kitchen does not and shall not discriminate on the basis of race, color, religion (creed), gender, gender expression, age, national origin (ancestry), disability, marital status, sexual orientation, or military status, in any of its activities or operations. These activities include, but are not limited to, hiring and firing of staff, selection of volunteers and vendors, and provision of services. We are committed to providing an inclusive and welcoming environment for all staff, clients, and volunteers.
Name (first & last) *
Birth date *
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Race/ethnicity
Phone number *
Delivery address *
Best way for us to contact you?
Clear selection
Caregiver name & contact *
Will caregiver be receiving meals?
Clear selection
Will you continue to work while on treatment or through recovery?
Clear selection
Income: Please check if persons in household/ total household annual income falls below 200% of federal poverty level
Physician's name / hospital
Dietitian Name (skip if not seeing a dietitian)
Have you met with or are planning to meet with your dietitian?
Clear selection
Are there any foods recommended you avoid?
Do you have any food allergies or are there foods you cannot tolerate? (we do our best to work with these factors, but cannot guarantee they won't be in meals)
Program gifting program *
If paying , how would you like to pay?
Clear selection
Delivery Time (delivery on Fridays)
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How did you find out about AMOR Healing Kitchen? *
Our client manager will be in touch soon to complete the application process. If you have any questions in the meantime, please call or email Katy Firth at 910.228.2557 or amorclientmanager@gmail.com
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