Homebound Meals New Client Application
Applications received after Noon on Thursday will not be processed until the following week. At this time - we are operating with no contact.
I understand that because of the pandemic, there will be NO CONTACT. I will need to have a cooler with a frozen ice pack at my door by 10:30 a.m.
I have a cooler and an ice pack to use
I do not have a cooler or an ice pack
Requested Duration of Services:
30 Business Days
To Be Determined
Street Address/Zip Code
HCOP (PV Only)
Emergency Contact Name (Mandatory) / Phone Number
Select the Medically Tailored Meal needed: All meals are designed and approved by registered dieticians and CANNOT be altered for preferences.
Low Vitamin K
Soft Food (Everything)
Low Fat Milk
Decaf Coffee Packet
Medications that effect diet (use N/A if not applicable) :
Diagnosed food allergy (use N/A if not applicable) :
Any notes that would help with this application:
Reason for services:
Do you have dog(s)
Conditions of Service - Must be checked as understood
A cooler and frozen ice pack are required for no contact no exceptions
To verify Homebound is delivering in bad weather, call 260.422.3296 AFTER 8 a.m.
To avoid charges, meals must be canceled by 6 am
Delivery times are estimated and will vary
Deliverers are volunteers
All questions/information must be called into office
Homebound can discontinue delivery at any time
Homebound can only accept 5 day a week clients
Clients are required to have a cooler by their entry door
Clients are required to have a frozen icepack in cooler by 10:30 am
Homebound will call EMS/Well Check if warranted
Homebound does not "hold" places on the route without prior arrangements
Homebound can only deliver to name/address on this application
24 hour notice required to discontinue service
Case Manager referrals require same Case Manager approval for diet & address changes.
Checking the yes below and accepting the first meal delivered, I accept all conditions of service
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Terms of Service