HMOW Financial Aid & Emergency Fund Form

HMOW is designed to reach out to county's older diverse community members especially the isolated, underserved, and often chronically disabled. The program started with 45 clients and now serves more than 600 older members and their families throughout the county. AMSS outreach has focused on zip codes with high concentrations of communities of color with health disparities.The program is conducted by teams of AMSS Multicultural Health and Long-Term Care Outreach Ambassadors who provide friendly phone calls, home visits, and the delivery of bi-weekly hot halal meals. In addition and to ensure proper nutrition for our seniors and their families, we are delivering along with hot meals non-perishable food, and fresh produce.

Learn about the program here: https://www.amssmd.org/halal-meals-on-wheels

Please answer all the questions, if you have any questions please

Email us: info@amssmd.org

Call us: 301-355-9961

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Email *
Name *
Email *
Address *
Phone number *
Gender *
Date of Birth *
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/
DD
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YYYY
What is your primary Language?  *
What is your country of origin?
What is your ethnicity? 
Emergency Contact  *

What is your Health Coverage? 

 *

Number of Household Members.

 *

Reasons for the financial aid: Please explain below the main reasons for applying for a financial and emergency fund or choose from the following options :

 *

How did you hear about AMSS? 

 *

Please note a copy of ID must be submitted for your final approval.

Learn about the program here: https://www.amssmd.org/halal-meals-on-wheels

Please answer all the questions, if you have any questions please

Email us: info@amssmd.org

Call us: 301-355-9961

A copy of your responses will be emailed to the address you provided.
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