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Meal Recipient Information
Delivery is available Monday through Friday.
Name
Date of birth
Phone number
Email
Address
Address
Address 2
City/Town
State/Province
- Select -
Alabama
Alaska
American Samoa
Arizona
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Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
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ZIP/Postal Code
PMI/Member #
Who are these meals for?
Me
My loved one
My client
Frequency
Pay source
Are you placing an order for someone else?
If so, please respond to the questions below.
Your name
Your phone number
Meal Information
Requested start date
We can generally begin service within three business days of receiving a completed application.
Preferred meal delivery day(s)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday (delivered during the week for reheating)
Sunday (delivered during the week for reheating)
Dietary needs and preferences
Regular diet
Diabetic-friendly
Low sodium
Low cholesteral/low fat
Other
Food allergies
Please list all food allergies, if applicable.
Delivery Instructions
Please deliver meals to
Front door
Side door
Back door
Other
If other, please explain
What should driver do upon arrival
Knock
Ring bell
Buzz apartment
Other
If other, please explain
Other Information
Does the person receiving meals live alone?
Yes
No
Does the person receiving meals have any pets?
Yes
No
Reason/cause for needing meals
Meal Recipient Demographics
LSS Meals does not discriminate on the basis of gender identity or race. We use gender and race data to track the effectiveness of our program. Your answers to the following questions are optional and will not affect your ability to receive services.
Gender
- None -
Male
Female
Other
Prefer not to answer
Race
- None -
White
Black or African American
Latino or Hispanic
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Other
Prefer not to answer
Questions: Call us toll-free at
800.488.4146.
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