Client Informtion – Johns Hopkins Elder Plus "*" 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)*Emergency 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 Has your spouse ever served in the military?* Yes No Have you ever served in the military?* Yes No Health, mobility, or dietary concerns we should be aware of:When would you like to begin service? (Please allow 3 business days)* MM slash DD slash YYYY Special dietary needs for delivered meals:* Yes No Days Requested:* Monday Tuesday Wednesday Thursday Friday Weekend 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:CAPTCHA Δ
