EDMOND MOBILE MEALS :: APPLICATION FOR SERVICES

APPLICATION FOR SERVICES: ELIGIBILITY

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

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

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

REGIONAL FOOD BANK

https://www.regionalfoodbank.org/get-help/

https://www.regionalfoodbank.org/

AREA-WIDE AGING SERVICES NUTRITION PROGRAMS:

https://www.areawideaging.org/projects

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

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

REGIONAL FOOD BANK

https://www.regionalfoodbank.org/get-help/

https://www.regionalfoodbank.org/

AREA-WIDE AGING SERVICES NUTRITION PROGRAMS:

https://www.areawideaging.org/projects

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 }

Has the applicant received a COVID-19 vaccine? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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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

What days of the week would the applicant like to recieve meals? [check all that apply] {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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

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Does the applicant have a caregiver or assistance on Saturday or Sunday? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Would the applicant like to receive a cold meal for the weekend? [cold weekend meals are delivered with Friday meals] {{ 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 of $3.50 per hot meal if doable. Please indicate 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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By submitting this application I agree to provide a safe environment for volunteers to deliver meals, including restraining any pets. I agree to cancel delivery by 9am if I will not be home during the delivery window, or I will incur a charge. I agree that if the applicant’s circumstance changes, and they no longer meet Edmond Mobile Meals qualifications, we will discontinue service.

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 }