CLIENT APPLICATION | Family, Client, & Other    (GEORGETOWN COUNTY)
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 & Georgetown 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.

Sign in to Google to save your progress. Learn more
Email *
DATE OF APPLICATION *
MM
/
DD
/
YYYY
APPLICANT LAST NAME *
APPLICANT FIRST NAME *
APPLICANT DELIVERY  ADDRESS | CITY, STATE, ZIP *
NEIGHBORHOOD (IF APPLICABLE)
APPLICANT CONTACT PHONE *
APPLICANT EMAIL ADDRESS
DATE OF BIRTH *
In your own words, tell us why you are requesting Meals on Wheels services. *
ETHNICITY / ORIGIN : BASED ON US CENSUS DEFINITIONS *
GENDER *
WHAT ZONE BEST DESCRIBES WHERE YOU LIVE?  (GEORGETOWN CITY LIMITS COMING SOON) *
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?
Clear selection
IF NO, WOULD YOU LIKE TO RECEIVE A QUILT OF VALOR?
Clear selection
YEARS SERVED IN THE MILITARY
WHAT WAS YOUR RANK?
DID YOU RECEIVE A PURPLE HEART?
Clear selection
DID YOU DEPLOY?
Clear selection
DID YOU SEE COMBAT?
Clear selection
WERE YOU HONORABLY DISCHARGED?
Clear selection
ARE YOU INTERESTED IN SHARING YOUR STORY WITH US?
Clear selection
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? *
EMERGENCY CONTACT & RELATIONSHIP TO YOU *
EMERGENCY CONTACT PHONE NUMBER | CELL *
EMERGENCY CONTACT PHONE NUMBER | HOME
EMERGENCY CONTACT EMAIL ADDRESS
EMERGENCY CONTACT ADDRESS | CITY, STATE, ZIP
SECONDARY CONTACT (EMERGENCY) & RELATIONSHIP TO YOU
PHONE NUMBER | CELL
PHONE NUMBER | HOME
EMERGENCY CONTACT ADDRESS | CITY, STATE, ZIP *
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
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?
Clear selection
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  ** *
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.
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.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms