CLIENT APPLICATION | Family, Client, & Other
Meals on Wheels of Horry County, Inc. provides home delivered meals to HOME BOUND individuals with no reliable means of getting groceries or safely preparing meals, regardless of ability to pay.  To be eligible, applicants must:

• Be over the age of 18
• Be home bound* and unable to meet basic nutritional needs ** either temporarily or long term
• Have no other reliable means of obtaining daily meals
• Reside in our service area (Horry County) and the availability must be open on designated route.

As long as clients meet all the above eligibility requirements, Meals on Wheels of Horry County, Inc. 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.

*Definition of “home bound”: Unable to leave the home without considerable difficulty and/or assistance.  A person may leave home for medical treatment or short, infrequent absences for non-medical reasons such as trip to the barber or religious services.

** Definition of “unable to meet basic nutritional needs”: Unable to prepare/have difficulty preparing at least one nutritious meal daily because of physical or mental limitations, or unable to obtain/have difficulty obtaining necessary food.
 
**Enter N/A if question not applicable.

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Name *
DELIVERY ADDRESS-STREET ADDRESS, TOWN, STATE, ZIP CODE *
NAME OF DEVELOPMENT OR APARTMENT COMPLEX
APPLIANT CONTACT PHONE NUMBER *
APPLICANT EMAIL
DATE OF BIRTH *
HOW ARE YOU OBTAINING YOUR MEALS AND GROCERIES NOW? 
 *
PLEASE PROVIDE A SHORT STATEMENT REGARDING WHY YOU ARE APPLYING FOR SERVICES *
ARE YOU ABLE TO DRIVE? *
ETHNICITY / ORIGIN : BASED ON US CENSUS DEFINITIONS *
GENDER *
DO YOU LIVE ALONE? *
IF NOT, WHO DO YOU LIVE WITH? (Name and relationship)
PRIMARY CARE DOCTOR *
PHYSICIAN PHONE NUMBER
We may need to contact your healthcare provider to verify information provided regarding health status. DO WE HAVE PERMISSION TO SPEAK TO THEM ON YOUR BEHALF?  *
EMERGENCY CONTACT & RELATIONSHIP TO YOU *
 *
EMERGENCY CONTACT PHONE NUMBER  *
EMERGENCY CONTACT ADDRESS | CITY, STATE, ZIP
EMERGENCY CONTACT EMAIL ADDRESS
DO YOU HAVE ANOTHER AGENCY IN YOUR HOME? (EG. HOME HEALTH, HOSPICE) *
IF YES, PLEASE PROVIDE THE AGENCY NAME
AGENCY CONTACT NAME & PHONE NUMBER
ARE YOU ABLE TO MEET THE DRIVER AT THE DOOR WHEN THEY DELIVER YOUR MEALS? *
IF NO, WILL SOMEONE BE AVAILABLE TO HELP ANSWER THE DOOR? MEALS MAY NOT BE LEFT OUTSIDE.
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DO YOU HAVE A MICROWAVE? *
Required
DO YOU HAVE HEARING ISSUES? *
Required
DO ANY OF THE FOLLOWING SPECIAL DIETARY NEEDS APPLY TO YOU? (Check all that apply)
If "Other" was checked, what special diet are you on? 
ANY ALLERGIES TO FOOD ?  *
DO YOU NEED ASSISTANCE WITH WALKING? *
Required
DO YOU HAVE DENTAL ISSUES? *
Required
DO YOU HAVE BREATHING PROBLEMS? *
Required
ARE YOU A DIABETIC? *
Required
DO YOU HAVE MEMORY ISSUES? *
Required
DO YOU HAVE ANY MENTAL HEALTH ISSUES? *
Required
PLEASE ADD THE MEDICAL CONDITION(S) THAT CAUSE YOU TO BE HOMEBOUND OR PREVENT YOU FROM BEING ABLE TO PREPARE YOUR OWN MEALS.  *
SPECIAL DELIVERY INSTRUCTIONS FOR THE DRIVER (IE HOUSE COLOR, LANDSCAPE, ENTRY CODE ETC.) *
ARE YOU A VETERAN OR SPOUSE OF A VETERAN? *
IF A VETERAN---WHAT BRANCH OF SERVICE DID YOU SERVE IN?
Do you grant Meals on Wheels permission to take your photograph with the potential that it may be used in a public manner (such as on social media)? *
MISSION STATEMENT:  Meals on Wheels of Horry County, Inc. glorifies our Lord Jesus Christ by providing home-delivered meals and fellowship to the homebound, elderly, and frail of Horry County.   BY TYPING MY NAME BELOW ON THIS APPLICATION, I ACKNOWLEDGE THAT MEALS ON WHEELS HAS IDENTIFIED SPECIFIC ELIGIBILITY REQUIREMENTS WHICH I HAVE READ AT THE TOP OF THE APPLICATION AND AGREE THAT I AM A CANDIDATE FOR THIS PROGRAM.  I AM AWARE THAT AT THIS TIME THERE IS NO COST TO PARTICIPATE IN THIS PROGRAM, HOWEVER I UNDERSTAND THAT THE MINISTRY IS RUN 100% BY DONATIONS FROM THE COMMUNITY AND THEREFORE ANY CONTRIBUTIONS ARE APPRECIATED BUT NEVER EXPECTED.  SHOULD A COST NEED TO BE CALCULATED IN THE FUTURE, I WILL BE NOTIFIED IN ADVANCE AND WILL BE MADE AWARE OF THE PROPOSED FEE.  I UNDERSTAND THAT MEALS ON WHEELS RESERVES THE RIGHT, AT ANY TIME AND FOR ANY REASON, TO DISCONTINUE THE SERVICE TO ME SHOULD MY CONDITIONS CHANGE WHERE I NO LONGER MEET CRITERIA, I REPEATEDLY FAIL TO ALERT THE KITCHEN WHEN I DO NOT NEED MEALS, I MOVE OUT OF THE CURRENT SERVICE AREA, OR THE SAFETY OF OUR VOLUNTEERS IS IN QUESTION WHEN AT MY RESIDENCE.   I AM ALSO AWARE THAT I MAY DISCONTINUE OR PUT ON HOLD THESE SERVICES AT ANY TIME. MY PRINTED NAME IS TO SERVE AS MY ELECTRONIC SIGNATURE.  IF I AM NOT THE PERSON THAT WILL BE RECEIVING THE MEALS, MY RELATIONSHIP TO THE APPLICANT IS NEXT TO MY NAME.  *
ASSUMPTION OF RISK AND WAIVER OF LIABILITY RELATING TO  MEALS ON WHEELS CLIENTS                                   
 Meals on Wheels takes your health and safety very seriously and we want to reassure you that we have taken all steps possible to ensure your well-being.  All individuals working in the kitchen and around the meals are required to wear gloves during all food preparations and are also required to complete a food safety course. By typing my signature below I agree to assume all liability for proper food storage or spoilage once food is delivered. Per South Carolina Department of Public health, food will not be left outside in any manner, including a cooler. I understand that Meals on Wheels also provides special deliveries of donated gifts throughout the year, such as for Easter and Christmas, but does not assume liability for contents of these gifts as they are provided by the community.   
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PERSON COMPLETING APPLICATION (if other than applicant)
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