Form Center

By signing in or creating an account, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.

Frederick County Department of Aging - Meals on Wheels and Home Delivered Meals Application

  1. ##/##/####

  2. ###-###-####

  3. Applicant Information

  4. ###-###-####

  5. ###-###-####

  6. ##/##/####

  7. #

  8. What is you primary language?*

  9. Do you require any hearing, vision, or language assistance?

  10. Contact Instructions

  11. Contact

    Please check one

  12. ### ### ####

  13. Applicant Demographic Information

  14. What sex do you identify as?*

  15. Ethnicity

  16. Race

    Check all that apply

  17. Marital Status*

  18. Did you or your spouse serve in the military?

  19. Are you a registered voter?

  20. Are there firearms or other weapons in the home?*

    Please be advised that all weapons are required to be unloaded and stored in a safe and secure manner when volunteers and staff make meal deliveries and home visits. Failure to do so could result in immediate suspension or termination of Meals on Wheels/Home Delivered Meals service.

  21. Pets in the house?

  22. Maryland Department of Aging - Food Security Screen

  23. 1. If you had groceries available, would you be able to use them to prepare meals?*

  24. 2. Do you have reliable help with meal preparation?*

  25. During the last month...

  26. 3. How often was this statement ? "The food that I bought just didn't last, and we didn't have money to get more."*

  27. 4. How often was this statement true? "We couldn't afford to eat balanced meals."

  28. 5. Did you or other adults in your household ever cut the size of your meals because there wasn't enough money for food?*

  29. 6. Did you or other adults in your household ever skip meals because there wasn't enough money for food?*

  30. 7. Did you ever eat less than you felt you should because there wasn't enough money for food?*

  31. 8. Were you ever hungry but didn't eat because you couldn't afford enough food?*

  32. #

  33. 9. Are you able to get groceries into your home when you need them?*

  34. Transportation

  35. Do you drive?*

  36. Do you use a van service?

  37. Do you depend on public but service?*

  38. Do you depend on family and friends?*

  39. Do you depend on a volunteer group?*

  40. Nutrition Screen

  41. Do you have a dietary influenced illness?*

  42. Do you eat less than 2 meals per day?*

  43. Do you have 3 or more alcoholic drinks per day?*

  44. Do you eat less than 5 servings of fruits, vegetables, and dairy products per day?*

  45. Do you have tooth or mouth problems making it difficult to chew or eat?*

  46. Do you lack money to buy food on a regular basis?*

  47. Do you usually eat alone?*

  48. Do you use 3 or more prescription and/or over the counter medications each day?*

  49. Have you lost or gained 10 pounds in the last 6 months without trying?*

  50. Are you unable to shop for food, cook, or eat regularly?*

  51. Diet Requirements

  52. Diet Requirements*

  53. Details

  54. Details

  55. * A prescription is required from your health care provider. Please note, not all MOW/HDM vendors preparing meals are able to provide prescription diets.

  56. While every attempt will be made to exclude allergy causing foods, the Frederick County Department of Aging and the meal vendors are not able to guarantee such food items, do not come in contact with, or are included in meals provided to Meals on Wheels/Home Delivered Meals clients. It is the individual meal recipients responsibility to examine the food provided, and avoid items that may cause an allergic reaction.

  57. Please note that Maryland Department of Aging regulations require specific food components be included in the meals provided to Meals on Wheels recipients. This program does not offer individual menu choices or accommodate specific food requests and substitutions.

  58. Health Conditions

    Check all that apply

  59. #

  60. Assistive Devices/Services

  61. Mobility:

    Check all that apply

  62. Hearing:

    Check all that apply

  63. Vision:

  64. Medication

    Please list all prescription, over-the-counter medications, and supplements

  65. Primary Health Care Provider

  66. ###-###-####

  67. ###-###-####

  68. Emergency Contacts

  69. ###-###-####

  70. ###-###-####

  71. ###-###-####

  72. ###-###-####

  73. ###-###-####

  74. ###-###-####

  75. Person responsible for financial contributions, if not applicant

  76. ###-###-####

  77. ###-###-####

  78. ###-###-####

  79. Agencies Currently Providing Assistance

  80. You may be eligible for additional benefits, services and assistance. A representative will contact you directly to discuss eligibility guidelines and application procedures.

  81. The information provided on this application is true and accurate to the best of my knowledge. I agree to allow Frederick County Department of Aging staff to complete a phone assessment and home visit/evaluation prior to being considered for Meals on Wheels/Home Delivered Meals services. I agree to allow Frederick County Department of Aging staff to share information with other staff, healthcare providers, partner agencies, and with representatives of agencies currently providing me with services, as appropriate. I agree to notify the Department of Aging if information on my application changes (i.e. emergency contact information). I have read and understand the Meals on Wheels/Home Delivered Meal criteria for service and the contribution policy and I would like to be contacted by a Department of Aging staff person to continue the application process.

  82. Return to the Frederick County Department of Aging by mail to: Frederick County Department of Aging, Attn: Meals on Wheels, 1440 Taney Ave, Frederick, MD 21702 or FAX to: 301-600-3554 or scan and email to: chock@FrederickCountyMD.gov

  83. Leave This Blank:

  84. This field is not part of the form submission.