PROGRAM TYPE Which program type are you interested in? Check all that apply. * Self Pay – NO WAITING LIST (Check, Credit Card, Food Stamps, Cash accepted. $5 per meal full price; $3.80 per meal using SNAP) Durham County Social Services – WAITING LIST * Donor Funded Meal Program – WAITING LIST * Emergency Meals - for individuals recently released from a hospital or rehabilitation center (2 WEEK DURATION) * There is a waiting list for no-cost meals. If you are able to pay for meals ($5/each or $3.80 if using SNAP), we can serve you more quickly. When will you be home from rehab / the hospital? Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year191419151916191719181919192019211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021 *DEPENDS ON QUALIFICATIONS & AVAILABILITY NEED FOR SERVICE What is your need for our services? Check all that apply. * Homebound Living alone Unable to cook Unable to shop MEDICAL QUESTIONS Do you have an illness or condition that made you change the kind of food you eat? * Yes No Do you eat fewer than 2 meals a day? * Yes No Do you eat few fruit and vegetables or milk products? * Yes No Do you have 3 or more drinks of beer liquor, or wine almost every day? * Yes No Do you eat alone most of the time? * Yes No Are there times that you do not always have enough money to buy the food you need? * Yes No Do you have tooth or mouth problems that make it hard for you to eat? * Yes No Do you take 3 or more different prescribed or over the counter drugs a day? * Yes No Have you gained or lost 10 pounds in the last 6 months without trying? * Yes No Are there times when you are not always physically able to shop, cook and/or feed yourself? * Yes No CLIENT INFORMATION First name: * Last name: * Street address: * Apartment Number Apartment Name City: * State: * North Carolina Zip code: * Phone number: * Email address (if any): Date of birth: * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year1914191519161917191819191920192119221923192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019 What is your disability? Race: * Are you a veteran? * Yes No Do you belong to a church / synagogue / mosque / faith community? Yes No If so, please let us know the name of your faith community Do you have a cat? Yes No Do you have a dog? Yes No EMERGENCY CONTACT INFORMATION First name: * Last name: * Phone number: * Relationship to client: * Email address (if any): PERSON COMPLETING APPLICATION Who is completing this application? * Client Other First name: Last name: Relationship to client: Is the client aware that you are submitting an application on their behalf? Yes No Phone number: Additional Comments CAPTCHAThis question is for testing whether or not you are a human visitor and to prevent automated spam submissions.