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 *
Date of application *
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Applicant last name *
Applicant first name *
Delivery address: street, town, state, zip *
Name of development or apartment complex
WHICH ZONE BEST DESCRIBES WHERE YOU LIVE? *
Applicant contact phone number *
Date of birth *
HOW ARE YOU OBTAINING YOUR MEALS 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
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?  *
EMERGENCY CONTACT & RELATIONSHIP TO YOU *
 *
EMERGENCY CONTACT PHONE NUMBER  *
EMERGENCY CONTACT ADDRESS | CITY, STATE, ZIP
EMERGENCY CONTACT EMAIL ADDRESS
SECONDARY CONTACT
PHONE NUMBER 
DO YOU HAVE ANOTHER AGENCY IN YOUR HOME? (EG. HOME HEALTH, HOSPICE) *
AGENCY NAME
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 UNDERSTAND THAT MY PICTURE WILL BE TAKEN AT MY INITIAL WELCOME VISIT BY THE MEALS ON WHEELS CARE TEAM TO ADD TO YOUR ELECTRONIC FILE TO HELP WITH IDENTIFICATION.  I UNDERSTAND THAT I WILL ALWAYS BE NOTIFIED BEFORE A PICTURE IS TAKEN DURING DELIVERIES, ACTIVITIES OR SPECIAL DELIVERIES.   *
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? 
Clear selection
WILL YOU BE ABLE TO HEAR THE DOORBELL OR KNOCK AT THE DOOR WHEN OUR DRIVER ARRIVES? *
DO YOU HAVE A MICROWAVE? *
DO THE FOLLOWING SPECIAL DIETARY NEEDS APPLY TO YOU? (Check all that apply)
ANY ALLERGIES TO FOOD ?  *
SPECIAL DELIVERY INSTRUCTIONS FOR THE DRIVER (IE HOUSE COLOR, LANDSCAPE, ETC.) *
ARE YOU A VETERAN OR SPOUSE OF A VETERAN? *
IF A VETERAN---WHAT BRANCH OF SERVICE DID YOU SERVE IN?
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. 
Meals on Wheels has a special team (2 individuals) of volunteers that will come and visit with you on or before your 2nd meal delivery to check in and make sure that your services are going well.  They will also share about our Care Team program and provide additional services and programs that are provided to our clients as part of our meal services.  **At this visit, our care team will ask to take a picture for identification purposes.** *
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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