Client Informtion – Johns Hopkins Medical Alliance "*" indicates required fields Name* First Last Address* Street Address Address Line 2 City ZIP Code County*Anne Arundel CountyBaltimore CityBaltimore CountyCarroll CountyFrederick CountyHarford CountyHoward CountyMontgomery CountyPrince George's CountyPhone (Home)Phone (Cell)Email Birthday* MM slash DD slash YYYY Race*American Indian or Alaskan NativeAsian or Asian AmericanBlack or African AmericanNative Hawaiian or Pacific IslanderWhitePrefer Not To AnswerEthnicity*Hispanic or LatinoNot Hispanic or LatinoHow did you hear about Meals on Wheels of Central Maryland?* Meals on Wheels Event Meals on Wheels Flyer Word of Mouth Print Publication Radio Internet Search Social Media Other What Program are you applying for?* Home Delivered Meals Grocery Assistance Program My Groceries To-Go!(ONLY Available to residents 60 & older residing in Baltimore City) Who should we contact regarding the application? (Name)*Who should we contact regarding the application? (Phone number)*Name of InstitutionEmergency Contact Full NameEmergency Contact Email Emergency Contact PhoneEmergency Contact Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Reason for needing assistance:*I am homebound* Yes No I am unable to shop or cook for myself* Yes No Have you ever served in the military?* Yes No Has your spouse ever served in the military?* Yes No Health, mobility, or dietary concerns we should be aware of:Special dietary needs for delivered meals:* Yes No When would you like to begin service? (Please allow 3 business days)* MM slash DD slash YYYY Days Requested:* Monday Tuesday Wednesday Thursday Friday Weekend Is this anticipated to be a temporary need following surgery, etc.?* Yes No Do you have a social worker or case manager assisting you from another agency?* Yes No Social Worker Name*Social Worker Phone*Social Worker Email* MONTHLY INCOME (Include all sources):*Please note: This information helps us determine a manageable fee based on your income and expenses. Please be prepared to provide your MONTHLY income and MONTHLY expenses during the scheduled telephone intake. Although documentation is not required, it is important that you report both your full income and all your expenses accurately. Failure to report all sources of income may result in an inability to initiate services. Please be prepared with the following information for our follow up call: BGE Personal Medical Care: In-Home aides, Ensure/Boost, Depends etc. Housing: Rent or Mortgage Rx/prescriptions cost Oil: heating (winter months) Medical/Doctor: Co-pays Telephone/Cable Transportation Taxes: Property, Outstanding IRS (Please specify) Water Insurance: Medical (out of pocket), Renters, Life, or Homeowners (Please specify) Name and phone number of Person Completing application:Name*Phone*In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, religious creed, disability, age, political beliefs, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA. Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the agency (state or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English. To file a program discrimination complaint, you may obtain a complaint form by sending an email to CR-Info@USDA.gov. You or your authorized representative must sign the complaint form. You are not required to use the complaint form. You may write a letter instead. If you write a letter, it must contain all of the information requested in the form and be signed by you or your authorized representative. Incomplete information will delay the processing of your complaint. Employment civil rights complaints will not be accepted through this email address. Compliance with Title IX is a joint responsibility. The USDA Office of the Assistant Secretary for Civil Rights (OASCR) and the National Institute of Food and Agriculture (NIFA) investigate complaints, conduct compliance reviews, and provide technical assistance and guidance. Title IX applies to any recipient of federal funds. Any applicant to, participant in, or employee of, a program receiving federal financial assistance from NIFA has the right to file a Title IX complaint through OASCR if they feel that they have been discriminated against or harassed based on their sex. Please see USDA DR 4330-002: Nondiscrimination in Programs and Activities Receiving Federal Financial Assistance from USDA as well as the Title IX Fact Sheet and Title IX Best Practices from NIFA Land Grant Universities. Program information is available in languages other than English. Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, and American Sign Language) should contact (1) the responsible State or local Agency that administers the program or (2) USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or (3) contact USDA through the Federal Telecommunications Relay Service at 711. Here are our addresses and fax number: Mail U.S. Department of Agriculture Director, Center for Civil Rights Enforcement 1400 Independence Avenue, SW Washington, DC 20250-9410 Fax: (202) 690-7442 Email: program.intake@usda.gov This institution is an equal opportunity provider. 02/27/2024 Thank you for submitting your application. Someone from our office will contact you within 3 business days to schedule your telephone intake..CAPTCHA Δ
