Meals on Wheels Application

Bergen County Division of Senior Services

Fax: 201-336-7424

Phone: 201-336-7420

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Emergency Contact Information
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Telephone Number
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INSTRUMENTAL ACTIVITIES OF DAILY LIVING: In the last 7-days, if you’ve had some difficulty in performing any of the following tasks by yourself, or required personal or standby assistance, or supervision, check ‘impairment’.
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ACTIVITIES OF DAILY LIVING In the last 7 days, if you’ve had difficulty or required any help in performing the following, check ‘impairment’.
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NUTRITION SCREENING The warning signs of poor nutritional health are often overlooked. This survey will help identify if you are at nutritional risk. Read the statements below. Check the appropriate column.
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The WELLNESS CHECK PROGRAM is an automated telephone reassurance program designed to check on the well-being of residents who live alone, are homebound, and over the age of 60, or age 18+ with a disability. Meals on Wheels participants are encouraged to enroll in this program.
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INDIVIDUAL RESPONSIBILITY
- You must be home to accept your meal delivery and make contact with the driver. Your driver can not leave your meal without knowing that you are safe.
- Drivers must have safe access to your door including but not limited to proper restraint or confinement of all pets during delivery.
- If you have a doctors’ appointment or will not be home, you must temporarily suspend your meal delivery by calling Meals on Wheels no later than 12:00 noon the business day before. You can leave a message any time of the day, 7-days a week.
- If you do not hear the door and find an ‘Attempted to Deliver’ tag left by the driver, or receive a voice message, call Meals on Wheels immediately at 201-336-7420. If we do not hear from you, we will stop your meal delivery and may call the police to check on your well-being.
- Repeated failure to suspend your delivery or late suspension may result in termination from the program. Food is a valuable resource that we cannot waste.
- A voluntary donation of $1.25 per meal is suggested. Please donate whatever you are able.
- We can only provide one meal a day, and we may not be able to deliver that meal as planned on any given day due to hazardous weather conditions or other unforeseen circumstances. You must keep food in your home at all times.
- Every 6-month a face-to-face assessment in your home is required to determine your eligibility to continue to receive home delivered meals and to provide possible referrals for other services to benefit you. A representative will contact you to schedule an appointment within a four--hour window. A family member or caregiver can be present if you wish.
Agree with the acknowledgement statement to submit the form.
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