Client Application | Meals on Wheels of Cheyenne

Please complete this form to sign up for services.

Once we have received your completed enrollment form, we will be in touch.

If you have not heard from our office within 48 hours, please call us at 307.635.5542

Today's Date

Your Information

Name

Phone

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Birthdate

Race

Are you disabled?

Do you live alone?

Do you family in the area?

Do you go to the senior center?

Do you own a pet?

If yes, what kind of pet do you own?

Who is your primary doctor?

Have you been diagnosed with any medical conditions?

If yes, please list medical conditions

What medications are you taking?

Do you have any food allergies?

If Yes, please list allergies

Height

Weight

Have you received the COVID-19 vaccination?

Yes

Meal Type

What type of milk do you drink?

Which Days Would You Like to Receive Meals? (Select All that Apply--Hold CTRL to select multiple days)

Special Delivery Instructions (hard of hearing, Knock and Wait, Call etc)

If yes, please list name and phone number

Emergency Contact #1

Name

Phone

Address

City/Town

State/Province

ZIP/Postal Code

Emergency Contact #2

Name

Phone

Address

City/Town

State/Province

ZIP/Postal Code

Would you like Vaccinated Volunteer Drivers to deliver meals inside your home?

	PLEASE CHECK THAT YOU HAVE READ AND UNDERSTAND THE FOLLOWING:
	Meal Cancellation or additions must be called in no later than 9:30am the day of delivery
	You can call our office 24 hours a day and leave a message with your name if you need to cancel.
	Meal delivery is normally between 11:00am and 1:00pm. Please note that outside factors (weather, traffic etc) may affect delivery time
	If you will not be home at time of delivery, please call the office to let us know you will not be home and leave a cooler outside for your meal. If you receive a message from us, please call us to let us know you have received your meal and are ok.
	If we do not hear from you and cannot reach you, we will attempt to contact your emergency contact(s) or contact the non-emergency police to do a wellness check, if necessary.
	Drivers are only able to deliver meals.
	I hereby grant Meals on Wheels of Cheyenne, Inc. all rights, title and interest in any and all photographs, video or audio recordings of or including my image or voice, to be used related to the mission of the organization.
	I understand that I am personally responsible for my behavior while receiving meals from Meals on Wheels of Cheyenne. If I am unable to avoid negative behaviors such as rude behavior, profanity, or threats, I may be dismissed from receiving meals.