Applicant Name *

First Name

Last Name

Applicant Phone #

(###)

###

####

Wenatchee

East Wenatchee

Please check the criteria that best describes your current situation:

Homebound (unable to travel to purchase food from a grocery store or restaurant)

Unable to prepare meals

Experiencing an injury, illness, or recovering from a surgery that causes a temporary hardship for obtaining meals

Receiving hospice or other related care

I have a caregiver who could provide meals

Emergency Contact Phone

(###)

###

####

Please select one:

Meals are prepared by Central Washington Hospital. Mobile Meals of Wenatchee/Central Washington Hospital is not responsible for food allergies or dietary requirements.

Entrée/starch/vegetable

Entrée/Two vegetables

Please select one:

Fruit

Dessert

Fruit or dessert on alternate days

OPTIONAL SELECTIONS:

Add Soup ($1.50 extra)

Add Salad ($1.50 extra)

Choose Delivery Days

Monday

Tuesday

Wednesday

Thursday

Friday

Payment Information

Mobile Meals currently asks each recipient to pay $5.50 per meal. Soup or salad adds $1.50 to the meal price. Depending on a recipient's ability to pay, this price may be reduced. The minimum price is $2.00. I will pay the following per meal.

$5.50

$7.00 with soup or salad

$8.50 with soup and salad

Other (add info below)

Payment will be made:

Weekly

Monthly

Please send a monthly Invoice

Yes

No

I would like my invoice:

Emailed

Mailed

Sent with Driver

This information is used for grant application purposes. Only summary data is used. Client names are never shared. Mobile Meals of Wenatchee serves all regardless of age, income, ethnicity, race, or gender.

Annual Income Level (based on a 1-person household)

Less than $24,999

$25,000-$49,999

Above $50,000

Prefer not to answer

Racial & Ethnic Background

African American

Asian or Pacific Islander

Caucasian

Hispanic

Native American or Alaskan Native

Other

Prefer not to answer

Age Group

0-6

7-12

13-18

19-25

26-54

55-70

70+

Prefer not to answer

Gender

Male

Female

Prefer not to answer