Application - Yukon, Oklahoma Mobile Meals

Full Name(required)

Date(required)

Home Address(required)

Address Directions(required)

Home Phone(required)

Note to Applicant: Understand that the meals will be a general diet. Special dietary needs can not be accommodated.

Food Allergies(required)

Health Problems or Dietary Restrictions(required)

Date of Birth(required)

Hearing(required)

Vision(required)

Ambulation(required)

Do you have pets?

Dogs

Cats

Other

Animals must be restrained during the time of meal delivery (10:45 a.m. - 12:00 p.m.) For the safety of the volunteers delivering your meal.

Physician Name(required)

Physician's Address(required)

Hospital Preference(required)

Suggested Donations(required)

$3 per meal

$15 Weekly

$60 Monthly

Other (Please contact our office)

Yukon Mobile Meals, INC. Does not receive any Federal or State funding.

Person to Notify in Case of Emergency:(required)

A Local Person that can be reached between 10:30 a.m. - 12:30 p.m.

Home Phone:(required)

Cell(required)

Work(required)

Next of Kin(required)

Address(required)

Home Phone:(required)

Cell(required)

Work(required)

Rules for Acceptance and participation in the program are the same for everyone without regard to race, color, national Origin, Age, Sex, or Handicap.