Meals On Wheels for Kids Application

Your information (for adult only, information for children will be collected later in application)

*required
First Name*: Middle Name:

Last Name*:

Phone Number* (555-555-5555)(where you can most easily be reached):

Secondary Phone:

Email*: Birthday (Month/Day/Year)*:

What is your current marital status?: SingleMarriedDivorceWidow

What is your relationship to the child/children listed in this application?*
MotherFatherGrandmotherGrandfatherUncleAuntSisterBrotherBabysitterOther

Eligibility

*required

Does your child participate in the free/reduced school breakfast/lunch program?* YesNo

Do you participate in SNAP or WIC programs?* NoYes, SNAPYes, WICYes, Both

Does your household have access to a working or reliable vehicle for life-sustaining trips: medical, grocery, work, job-related training/education and other vital services?* YesNo

Is your household lead by adult with a disability or illness?* YesNo

Will an adult 18 yrs or older be home during meal delivery?* NoYes

How did you hear about Meals On Wheels for Kids?
SchoolPantryFlyerSelfSomeone who receives mealsOtherSocial MediaTV/News/PrintFamily/FriendInternetSocial Worker/Case ManagerVolunteer

Address & Household Information

*required

Address*: Apartment #:

Name of Apartment Complex / Gate Code:

City*: Zip*:

County*: HillsboroughPascoPinellas

Number of people that live in the child's household*:

Number of children that live in your household (18yrs or younger)*:

Number of pets in the household*: 1 or more cats1 or more dogs0

Primary language spoken in the household*: EnglishSpanishOther

Net household income, after taxes*:

How does your family identify the race of the household?* Select all that apply.
Asian or Pacific IslanderNative American or American IndianBlack or African AmericanOtherHispanic or LatinoWhite

Information about child/children

FOR EACH CHILD, list the FIRST NAME, LAST NAME, GENER, BIRTHDAY, and SCHOOL below.* (required)

Secondary contact information (provide contact information for someone who will be home to receive the delivery, in the event that you will not be home)

First Name:

Last Name:

Phone:

Relationship to child/children:MotherFatherGrandmotherGrandfatherUncleAuntSisterBrotherBabysitterOther

Please read and respond to the following Meals On Wheels for Kids (MOW4Kids) statements:

*required

I acknowledge that MOW4Kids, a Tampa Bay Network to End Hunger (TBNEH) program, will be delivering meals for the child/children at the address listed above when school is not in session or when child/children are attending school remotely or virtually from home. These meals will be delivered by volunteer drivers who have been background checked. I give permission for the MOW4Kids drivers to deliver meals to the child/children listed above, even if no responsible adult is present.*
YesNo

I will enforce social distancing and I understand that volunteer drivers delivering the food will enforce social distancing. I will allow volunteers to place the delivery items at my front door, then knock on the door or ring the doorbell, and step away, while someone from my home retrieves the items. I will practice social distancing by not touching the volunteers, taking food from each other, or being within 6 feet.*
YesNo

I understand that if I live in an apartment complex, volunteers will call me when they are 15 minutes away. I will meet the volunteer at the front of the apartment complex to receive my delivery, if I am physically able to do so. I will stand back and practice social distancing, while awaiting direction from volunteers to retrieve the delivery.*
YesNo

I understand that MOW4Kids deliveries may contain nuts, wheat, soy, fish, eggs, or dairy, etc.*
YesNo

I understand that someone must be home to receive the delivery between 10am-2pm on the delivery day. I will notify MOW4Kids by calling 813-344-5837 if no one will be home to receive the delivery. I will notify MOW4Kids at least 2 business days (M-F) before my scheduled delivery. If I don't call in advance and no one is home to receive the delivery, I will no longer be able to participate in the program.*
YesNo

Sign and Date

*required

First and Last Name*: Date*:

Please click ‘Submit’ when all fields have been completed.