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Client Registration Form

Home > Volunteer Food Services > Client Registration Form

First name: *

Family name at birth: *

Family name used now (if different from birth name):

Gender: *

Female
Male

Language(s) spoken: *

French
English
Other

Specify

Date of birth: *

Address line 1 : *

Address line 2 :

Postal code: *

Cross street: *

Entry code:

Ville : *

State *

District

Telephone (example: 514.555.1212): *

Indicate the area code

Specific characteristics

Please check the appropriate box(es):*

Diabetic dessert
Cognitive problems (specify below)
Hearing impaired (specify below)
Visually impaired (specify below)
Slow to answer (specify below)

Does the beneficiary have any food allergies or restrictions? *

Reason for service request / Other information: *

Recommended frequency:

The client is aware of and in agreement with this request: *

Yes
No

Can we communicate directly with the client to set up the service?: *

Yes
No

Other persons living at the same address

Does the above mentioned person live alone?: *

Yes
No

If you have checked No, and the other persons at this address require Meals on Wheels, please indicate the surname, name, date of birth and other relevant information in the following space:

Contact person

Name of the contact person: *

Relationship: *

1st Telephone (example: 514.555.1212): *

Extension 1st Telephone:

Home, Work or Cellular?:

Home
Work
Cellular

2nd Telephone (example: 514.555.1212):

Extension 2nd Telephone:

Home, Work or Cellular?:

Home
Work
Cellular

Professional section

Referred by: *

Telephone (example: 514.555.1212): *

Extension:

Institution: *

If you selected "Other institution", please specify:

Email: *

If you would like a copy of your answers for your files, please print this form BEFORE clicking "submit".

For further information, please contact the Liaison Officer, at 514.842.3351 ext:223.

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Client Registration Form

Specific characteristics

Other persons living at the same address

Contact person

Professional section

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