HMOW Consent 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.

The American Muslim Senior Society (AMSS) “Halal Meals on Wheels” reflects AMSS mission to serve the long-term care needs of seniors, and caregivers, who are isolated and cannot access essential services. The AMSS Ambassadors' role will be to conduct monthly visits, make friendly calls, and provide services to caregivers by connecting them through our partnership with the appropriate agencies in Montgomery County. You have been selected by AMSS to be among the members of Montgomery County to receive AMSS “Halal Meals on Wheels”. A Team of two ambassadors will be setting up a time to visit you to: introduce themselves, explain the work plan, answer all your questions, and get your permission to be part of the “Halal Meals on Wheels Program”. We assure you that we will keep the confidentiality of your information. Also, you have the right to decline any service that does not agree with your culture or beliefs. Translated material will be provided upon your request

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

Sign in to Google to save your progress. Learn more
Email *
Name *
Email *
Full Address *
Phone number *
Gender *
Date of Birth *
MM
/
DD
/
YYYY

Please note a copy of ID must be submitted

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.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of American Muslim Senior Society.

Does this form look suspicious? Report