Get Started

Client Registration

Complete the form below or call 219.872.9117 to register for meal delivery services.

Reason for Services

Homebound
Living alone
Unable to cook
Unable to shop

Client Name

First

Last

Apartment Name

Apartment Number

Phone Type

Home
Mobile

Email Address

Gender

Female
Male

Ethnicity

White
Black
Hispanic
Asian

Do you live alone?

Yes
No

Housemate Name

Are you a veteran?

Yes
No

Do you have a dog?

Yes
No

Do you have a cat?

Yes
No

Emergency Contact Name

First

Last

Relationship to Client

Who is completing this registration?

Client
Other

Applicant Name (if other)

First

Last

Relationship to Client

Primary Care Doctor

Recent Illness or Accident

Other (please specify)

Food Allergies?

Yes
No

List foods you are allergic to

Potential Medication/Food Interaction?

Yes
No

List medications

Illness that changed food intake?

Yes
No

Eat fewer than 2 meals a day?

Yes
No

Eat few fruits/vegetables or milk products?

Yes
No

Eat alone most of the time?

Yes
No

Times without enough money for food?

Yes
No

Tooth or mouth problems affecting eating?

Yes
No

Take 3+ prescribed/OTC drugs daily?

Yes
No

Lost or gained 10 lbs in last 6 months?

Yes
No

Physically unable to shop or cook?

Yes
No

Meal plan interest

One Meal
Two Meals
Frozen Weekend Meals

Is monthly income over $1,470.00?

Yes
No

Housing expense type

Mortgage
Rent
Own my Home

Monthly rent/mortgage payment

Average monthly prescription expense

How did you hear about us?

Please specify (if Other)

Message

Together, we can deliver.^®

One last thing

100,000 meals start with $8.

Whatever you give today goes back into the community — feeding neighbors right here in LaPorte County. Thank you.

Donate now →