Meal Registration

"This has been the perfect solution for our family. Its great knowing our mom is getting one good meal a day."

Complete this form if you're wanting to begin a meal program. The intake coordinator will call you to complete the registration.

Client Information

Name: *

Address Line 1: *

Address Line 2:

City / Town: *

Postal Code: *

Phone Number: *

Date of Birth: *

Ontario Health Card Number : *

Is there a second person at this address who will also receive meals? Please add their Name, Date of birth, Ontario Health card :

Name of person completing this form: *

Phone Number of person completing this form: *

Email address of person completing this form: *

Client Details

How did you find out about our program?:

Are you interested in the standard meal program or the frozen meal program? : *

Standard Meal Program

Frozen Meal Program

Any food allergies?:

Any difficulties chewing or swallowing?:

Diet restrictions? (eg diabetic, No added salt):

Emergency Contact #1 Information

Name:

Address Line 1:

Address Line 2:

City / Town:

Postal Code:

Phone Number:

Emergency Contact #2 Information

Name:

Address Line 1:

Address Line 2:

City / Town:

Postal Code:

Phone Number:

Comments / Questions / Requests:

Meals on Wheels London, Ontario