EDMOND MOBILE MEALS :: APPLICATION FOR SERVICES

APPLICATION FOR SERVICES: ELIGIBILITY

Is the applicant over the age of 65 or immunocompromised? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Due to COVID-19, we are currently limiting new enrollments to those who are over the age of 65, or are immunocompromised and living alone. If you are under the age of 65 and in need of food, please contact:

Regional Food Bank of Oklahoma at: https://www.regionalfoodbanck.org/

or Project 66 at (405) 341-1353.

Is the applicant, or someone else, able to come to the door when meals are delivered? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Due to risk of transmission of COVID-19, volunteers are unable to enter residences. Please locate someone who can answer the door during delivery and then re-start the application process.

Is the applicant or someone else in the house currently experiencing symptoms of COVID-19, or has the applicant or someone else in the house tested positive for COVID-19 within the last 14 days? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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For the safety of our volunteers, we are unable to provide service to those with COVID-19 symptoms, or households where a resident is experiencing COVID-19 symptoms.

Edmond Mobile Meals service area covers Edmond zip codes. To find your local meal program, visit Meals on Wheels of America at the link below and enter your zip code.

https://www.mealsonwheelsamerica.org/find-meals

Is the applicant homebound? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Edmond Mobile Meals service is reserved for the homebound elderly and disabled residents of Edmond who are unable to prepare a meal for themselves and do not have a caregiver during the daytime. A homebound individual is defined as someone who does not normally leave their home, cannot drive and unable to shop for groceries or go to restaurants. Service cannot be provided due to: financial constraints or not having a vehicle.

Visit these resources for programs that may be a fit for your circumstance:

To Find Food Banks Near You:

https://www.regionalfoodbank.org/get-help?gclid=EAIaIQobChMIo9XmjZfb5AIVh8DACh1jOgOoEAAYAiAAEgKXD_D_BwE

Area-Wide Aging Services Nutrition Programs:

http://www.areawideaging.org/fundedprograms/nutritionprograms.html

Does the applicant have a caregiver or assistance during the daytime, Monday - Friday? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Edmond Mobile Meals service is reserved for the homebound elderly and disabled residents of Edmond who are unable to prepare a meal for themselves and do not have a caregiver during the daytime. A homebound individual is defined as someone who does not normally leave their home, cannot drive and unable to shop for groceries or go to restaurants. Service cannot be provided due to: financial constraints or not having a vehicle.

Visit these resources for programs that may be a fit for your circumstance:

To Find Food Banks Near You:

https://www.regionalfoodbank.org/get-help?gclid=EAIaIQobChMIo9XmjZfb5AIVh8DACh1jOgOoEAAYAiAAEgKXD_D_BwE

Area-Wide Aging Services Nutrition Programs:

http://www.areawideaging.org/fundedprograms/nutritionprograms.html

Are you making this application on behalf of yourself or someone else? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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How is the applicant currently getting meals? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

What else can you tell us about the applicant's situation that will help us in assisting them? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

APPLICANT: GENERAL INFORMATION

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Home Phone [include area code] {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Cell Phone [include area code] {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Date of Birth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Gender {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Race [check all that apply] {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Is the applicant a Veteran? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Does the applicant live alone? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Who lives in the home with the applicant? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Are there pets in the applicants home? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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What type of pet? [check all that apply] {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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EMERGENCY CONTACT #1

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Cell Phone [include area code] {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Other Phone [include area code] {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Relationship to applicant? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Would you like to add another 'emergency contact'? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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EMERGENCY CONTACT #2

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Cell Phone [include area code] {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Other Phone [include area code] {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Relationship to applicant? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Would you like to add another 'emergency contact'? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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EMERGENCY CONTACT #3

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Cell Phone [include area code] {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Other Phone [include area code] {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Relationship to applicant? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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MEAL INFORMATION

Until further notice, Edmond Mobile Meals will deliver 5 days of prepared meals each Wednesday. If you wish to receive these meals, please continue with the application process.

Continue with Application? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Would the applicant like to receive a carton of 2% milk with their meal? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Please provide special delivery instructions. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Does the applicant have a working doorbell at their residence? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Please provide additional special delivery instructions. [security gate codes, call prior to delivering, etc.] {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

When would you like to begin meal delivery? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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FINAL APPLICATION DETAILS

Edmond Mobile Meals recommends a contribution towards the cost of each meal. Please let us know what you are able to contribute. [we will send an invoice at the end of each month] {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Should statements be sent to applicant or someone else? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Please send statements to:

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Phone 1 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Phone 2 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Relationship to recipient? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Is this application being submitted by the recipient or someone else? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Application submitted by:

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Phone 1 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Phone 2 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Relationship to recipient? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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I understand that I may be eligible to receive once a week meal delivery on a temporary basis due to the COVID-19 pandemic, and continuation of service when normal meal services resume is dependent upon meeting the usual qualifications, and my status as a client will be reviewed at that time. Service may be discontinued if I do not meet those qualifications.

I understand and agree to these terms: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Please tell us how you heard about Edmond Mobile Meals {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }