Meals on Wheels Application Form

Name*
First Last
Email address*
Primary phone number*
What is your relationship to the applicant?*
- Self
- Relative
- Friend/ Neighbor
- Agency
Please tell us which agency you are a part of.
Recipient Information
Please complete the following information about the meal recipient.
Recipient's name*
First Last
Recipient's address*
Recipients of Feed More's Meals on Wheels must reside in the following areas of Virginia: the cities of Richmond, Petersburg, Colonial Heights or Hopewell, or the counties of Charles City, Chesterfield, Dinwiddie, Goochland, Hanover, Henrico, Louisa, New Kent, Powhatan or Prince George.

Street Address Address Line 2 City State ZIP Code
Recipient's phone number*
Recipient's gender*
- Female
- Male
Recipient's race
Recipient's date of birth*

Emergency Contacts
Please list those we can discuss the recipient's well being with or contact for emergency purposes.
Contact Name*
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Phone Number*
Secondary Phone Number
Relationship to Recipient
Contact Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Phone Number
Secondary Phone Number
Relationship to Recipient
Physician Information
Please list the recipients primary care physician contact information.
Physician's Name
First Last
Physician's Phone Number

Meals for Pets Program
Feed More’s Meals on Wheels has a Meals for Pets Program! Pet food, when available, is delivered once a month during regular meal delivery for a recipient. All pet food is donated and free of charge.
Does the recipient need pet food delivered?*
- Yes
- No
Number of small dogs
Number of medium sized dogs
Number of large sized dogs
Number of cats
Does your pet prefer:
Cost of Meal Service
Feed More’s Meals on Wheels service fee is either $6 or $11, based on the level of service associated with meal delivery. A limited number of sponsorship opportunities are available through Senior Connections, Jefferson Area Board for Aging (JABA), Crater District Area Agency on Aging and directly through Feed More. Applicants may request a reduced or waived service fee and will be required to provide additional information to support their request. No one will be turned away based on income.
Would you like Feed More to work with you on a reduced meal fee?*
By completing this form, applicant certifies that consent is given for Feed More’s Meals on Wheels to share information with partner agencies.*
I agree

Giving Food