La Jolla Meals On Wheels Client Application

Fields marked with an * are required

Name *
Phone *
Date of Birth *
Date of Birth
Housing Type
Does anyone live with you
Type of drink required
Emergency Contact Information
Phone number of Emergency Contact
Phone number of Emergency Contact
Additional Emergency Contact - optional
1. I would like to apply for Meals-on-Wheels. I understand that the cost will be $7.50 per day for one hot meal and one cold meal; 2. The meals will be delivered to my door on a daily basis - Monday through Friday, including holidays; 3. I will give at least 2 business days’ notice if I wish to cancel the Meals-on-Wheels program; 4. Except in the case of medical emergencies, if I need delivery stopped for one day, I will call the office at least 2 business days in advance.
I agree to the above provisions. *