ࡱ>  4bjbj rrC  lll<D$8$:$:$:$:$:$:$$e&)^$l!!!^$  s$###! l8$#!8$##^#b2!#$$$0$#)v")#)l#,#QE^$^$"#^$!!!!) :  HANOVER AREA COUNCIL OF CHURCHES 136 CARLISLE ST. PO BOX 1561 HANOVER, PA 17331 PHONE: 717-633-6353 FAX: 717-633-6219 Email: adminhacc@comcast.net MEALS ON WHEELS CLIENT APPLICATION  NAME _____________________________________________________________________________ (LAST) (FIRST) (MIDDLE INITIAL) ADDRESS _____________________________________________________________________________ (NUMBER & STREET) (APT./LOT NUMBER) CITY ______________________ STATE ________ ZIP ______________ PHONE: _________________ DATE OF BIRTH ___________ SEX: M or F (please circle)  START DATE: ___________________ END DATE: ________________ DAYS FOR DELIVERY: M T W TH F (please circle) PETS? Y or N DESCRIBE______________________________________________ (please circle) ANY FOOD RESTRICTIONS/FOOD ALLERGIES: ______________________________ SPECIAL INSTRUCTIONS/DELIVERY INSTRUCTIONS: _______________________ _____________________________________________________________________________  Please circle all conditions that apply: Alzheimers Cancer Dialysis Paralysis Amputee Cataracts Emphysema Seizures Arthritis Deafness Hard of Hearing Stroke Asthma Dementia Heart Disease Vision Problem Bed-Ridden Depression High Blood Pressure Blindness Diabetes Lung Disease Other: ______________________________________________________________________ Please circle any aids currently used: Cane Glasses/Contacts Hearing Aid Oxygen Pacemaker TTY/Phone Walker Wheelchair Other: ______________________________________________________________________  Do you use a home health aide or home nurse service? Y or N Do you receive help from other organization(s) Y or N If so, which one(s)? _____________________________________________________________________________  NAME:_________________________________________ ADDRESS: _____________________________________ City, State, Zip: __________________________________ Phone: __________________ Fax: _________________  I authorize the release of my medical condition and other information to and among agencies and their agents necessary to determine appropriate services for my care. I understand that I may revoke this release of information in writing. Person completing application: ______________________________________________ (signature) Date: ________________ ______________________________________________ Relationship to client (if other than client) Client Name: ____________________________ Date of Birth: ________________ Address: ____________________________ City, State, Zip __________________________  REFERRING AGENCY: ___________________________ Address: _________________________________________ City, State, Zip ____________________________________ Phone: ________________ Fax: ______________ Email: ______________________ Signature: ________________________________ (must be hand signed/ No signature stamp please) Title: _____________________________________ Vision: _____________ Walking: _______________ Hearing: __________________ Mental Capacity: ____________________ Other: _____________________________ Length of time to receive Meals on Wheels: ________________________  1. Name: ______________________________________ Address: ____________________________________ City, State, Zip: ______________________________ Home Phone: ________________ Work Phone: _____________ Cell Phone: _________ Email Address: _________________________________________ Relationship to Client ___________________________________ Does this person have a key to the clients home or apartment? Y or N 2. Name: ______________________________________ Address: ____________________________________ City, State, Zip: ______________________________ Home Phone: ________________ Work Phone: _____________ Cell Phone: _________ Email Address: _________________________________________ Relationship to Client ___________________________________ Does this person have a key to the clients home or apartment? Y or N _____________________________________________________________________________ HANOVER AREA COUNCIL OF CHURCHES 136 CARLISLE ST. PO BOX 1561 HANOVER, PA 17331 PHONE: 717-633-6353 FAX: 717-633-6219 Email: adminhacc@comcast.net CLIENT INFORMATION DELIVERY INFORMATION MEDICAL INFORMATION OTHER INFORMATION PHYSICIAN INFORMATION MEALS ON WHEELS REFERRAL FOR SERVICE Referral is required by Clergy, Visiting Nurse Association, Hospital, Physician, or other Social Service Agency. 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