Sign Up Chose the service you are interested in, complete the form and we will be in touch! Meals on Wheels Lunch Club Big Day Out Meals on Wheels Are you the recipient? Yes No Recipient Name Landline Number Mobile Number Email Address (optional) Addess Are there any access issues to the property or any specific directions (if the property is hard to find) Emergency contact name, address, phone number and email.We only contact the Emergency contact if there is no access to the home for a planned delivery or if there is no answer on the recipients phone. We would also make contact if we felt the beneficiary was showing signs of severe illness, distress, or confusion. Does the recipient live alone Yes No What age is the recipient Is the recipient classed as a carer (for a partner or family member living in the same home) Yes No Does the recipient have a mobility issue or physical impairment that means they may take longer to answer the door Yes No Does the recipient have a mobility issue or physical impairment that requires the delivery driver to put the food in the fridge for them Yes No Is the recipient hearing or sight impaired Yes No Does the recipient have dementia or a cognitive impairment Yes No Does the recipient give permission for the delivery driver to enter the home if required Yes No please provide any details regarding any mobility issues or physical impairments (optional) Do they have any allergies or intolerances Yes No Please provide details of Alergies Are there any food items they don't like and would never want included in a meal Do they have a microwave for reheating the meals safely Yes No Do they want fresh food delivered on a tuesday and/or friday Tuesday Friday Both Friday & Tuesday How many meals per week would they like Send Lunch Club Guest Name Landline Phone Number Mobile Number Which Thursday would you like to attend? Your meal on the day will cost just £8 and includes 3 courses meal Please confirm your payment option Pay in advance Cash or card on arrival Do they have any allergies or intolerances Yes No Please provide details of Alergies Send Big Day Out Guest name Which event would they like to attend? Visit to XXXXX September xxth Tour of the xxx September xxth Visit to XXXXX octoberr xxth Phone number Guest age Emergency contact name, address, phone number and email.We only contact the Emergency contact if we felt the guest was showing signs of severe illness, distress, or confusion. Do they have a mobility issue or physical impairment Yes No Does the guest use a wheel chair? Yes No Are they hearing or sight impaired Yes No Do they have dementia or a cognitive impairment Yes No If you have answered is yest to any of the above please provide further detailsPlease provide detials Do they have any allergies or intolerances Yes No Please provide details of allegies Send
