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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Email *
I REPRESENT THE CONWAY POLICE DEPARTMENT SENIOR WATCH PROGRAM. *
DATE OF APPLICATION *
MM
/
DD
/
YYYY
APPLICANT LAST NAME *
APPLICANT FIRST NAME *
APPLICANT DELIVERY ADDRESS *
CITY / STATE *
ZIP CODE *
NEIGHBORHOOD (IF APPLICABLE)
APPLICANT CONTACT PHONE *
DATE OF BIRTH *
ETHNICITY / ORIGIN : BASED ON US CENSUS DEFINITIONS *
GENDER *
ARE YOU NEW TO HORRY COUNTY?
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WHAT ZONE BEST DESCRIBES WHERE YOU LIVE? *
DO YOU LIVE ALONE? *
IF NOT, WHO DO YOU LIVE WITH? (NAME & RELATIONSHIP)
HOW DO YOU CURRENTLY RECEIVE YOUR MEALS / GROCERIES? *
ARE YOU A VETERAN OR THE SPOUSE OF A VETERAN? *
WHAT IS THE VETERANS NAME?
IF YES, BRANCH OF SERVICE (THANK YOU FOR YOUR SERVICE)
HAVE YOU EVER RECEIVED A QUILT OF VALOR?
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IF NO, WOULD YOU LIKE TO RECEIVE A QUILT OF VALOR?
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YEARS SERVED IN THE MILITARY
WHAT WAS YOUR RANK?
DID YOU RECEIVE A PURPLE HEART?
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DID YOU DEPLOY?
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DID YOU SEE COMBAT?
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WERE YOU HONORABLY DISCHARGED?
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ARE YOU INTERESTED IN SHARING YOUR STORY WITH US?
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WERE YOU REFERRED TO MEALS ON WHEELS? *
IF YES, BY WHO? (NAME & RELATIONSHIP)
PRIMARY CARE DOCTOR NAME *
DOCTOR PHONE NUMBER *
DUE TO THE CHANGES ASSOCIATED WITH COVID-19, WE NOW REQUIRE A REFERRAL FORM COMPLETED BY A HEALTH CARE PROVIDER THAT CAN ANSWER ANY ADDITIONAL QUESTIONS AND VERIFY ELIGIBILITY OF THE PROGRAM. DO WE HAVE PERMISSION TO SPEAK TO THEM ON YOUR BEHALF? *
PRIMARY CONTACT & RELATIONSHIP TO YOU *
PHONE NUMBER | CELL *
PHONE NUMBER | HOME
SECONDARY CONTACT (EMERGENCY) & RELATIONSHIP TO YOU
PHONE NUMBER | CELL
PHONE NUMBER | HOME
CHURCH / RELIGIOUS ORGANIZATION
PASTORAL CONTACT (NAME & PHONE NUMBER)
DO YOU HAVE ANOTHER AGENCY IN YOUR HOME? (I.E. HOME CARE, HOSPICE, HOME HEALTH, PRIVATE CAREGIVERS) *
IF YES, NAME OF AGENCY IN HOME?
AGENCY CONTACT NAME & PHONE NUMBER
BY AGREEING TO THIS STATEMENT, YOU UNDERSTAND THAT VOLUNTEERS MAY REQUEST TO TAKE A PICTURE OF YOU, HOWEVER YOU HAVE THE RIGHT TO DECLINE AT THE TIME OF THE VISIT. IF WE USE THE PICTURE WITH YOUR APPROVAL, MEALS ON WHEELS OF HORRY COUNTY, INC. HAS PERMISSION TO USE MY PICTURE FOR NEWSLETTERS, EDUCATION, EMPOWERMENT, SOCIAL MEDIA AND/OR MARKETING REASONS. I WILL ALWAYS BE NOTIFIED BEFORE A PICTURE IS TAKEN. *
HAVE YOU BEEN ON A MEALS ON WHEELS PROGRAM BEFORE?
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IF YES, WHAT CITY / STATE?
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?
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IF SOMEONE IS NOT AVAILABLE TO ANSWER THE DOOR, WE ARE UNABLE TO LEAVE THEM OUTSIDE. WHAT OPTIONS DO WE HAVE TO ENSURE YOU RECEIVE THE MEALS?
WILL YOU BE ABLE TO HEAR THE DOORBELL OR KNOCK AT THE DOOR WHEN OUR DRIVER ARRIVES? *
DO YOU HAVE OXYGEN IN THE HOME? *
DO YOU HAVE A MICROWAVE? *
DO THE FOLLOWING SPECIAL DIETARY NEEDS APPLY TO YOU? (Check all that apply)
ANY ALLERGIES TO FOOD ** *
DAYS OF SERVICE REQUESTED (CHECK ALL THAT APPLY) *a bottle of water will be provided. *
Required
SPECIAL DELIVERY INSTRUCTIONS FOR THE DRIVER (IE HOUSE COLOR, LANDSCAPE, ETC.) *
IS THERE ANY ADDITIONAL INFORMATION THAT YOU FEEL WE SHOULD KNOW ABOUT YOU THAT WILL BETTER ASSIST US IN SERVING YOU AT MEALS ON WHEELS? *
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. I ACKNOWLEDGE THAT IN ADDITION TO THIS APPLICATION, A MEDICAL APPLICATION MUST ALSO BE COMPLETED BY A REPRESENTATIVE THAT KNOWS MY MEDICAL / PHYSICAL CONDITION AND SENT TO MEALS ON WHEELS FOR FINAL APPROVAL. 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 RAN 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. 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 COVID-19 FOR MEALS ON WHEELS CLIENTS The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person to person contact. As a result, federal, state, and local governments and (DHEC) health agencies recommend social distancing, thorough and frequent hand washing, limiting contact with large groups of people, and wearing face masks.You are our number one priority. 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 them meals are REQUIRED to wear masks and gloves during all food preparations, packing of bags, and delivering the meals to your homes. Even with the measures that Meals on Wheels has put in place to reduce the spread of COVID-19, we cannot guarantee that you and/or your family will not become infected while volunteering. By typing my name below on this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risks associated with the disease. I agree with the steps and precautions that Meals on Wheels has implemented to keep me safe and do not hold any liability over Meals on Wheels for the possible spread of COVID-19. I am aware that this program that I am participating in is voluntary and I can cancel and put on hold at any time should I feel necessary. *
ADDITIONAL NOTES FROM CLIENT INTAKE COORDINATOR DURING THE INTERVIEW.
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