Participant Registration Form

Senior Nutrition Program Registration Form (Home Delivered Meal Program & Senior Cafe)

  1. Senior Nutrition Registration Form

    The Senior Nutrition Program (SNP) provides on-site and home-delivered meals for older adults throughout Washtenaw County to maintain health, housing stability, and independence.  Seniors 60 and over have access to this program and meals are available at a suggested donation of $3 per meal.  No senior is ever turned away for lack of payment or donation.  Guests under 60 are required to pay $5.50 per meal.

  2. Demographic Information

    Please complete this section of information as it is very important to our program.  This information allows us access to funding based on the demographics of our participants.  Your information is only shared as data outside of our program.  All demographic information is used for grants, advocacy and fundraising. All information is shared data and aggregate information it is not shared in a way that it can be traced back to you as a individual.

  3. I decline to provide answers to these demographic questions
  4. Gender
  5. Client Sexual Orientation
  6. Marital Status
  7. Race
  8. Are you Hispanic/Latino
  9. Current Living Arrangements
  10. Yearly Household Income (estimated)
  11. Electronic Signature Agreement
    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
  12. Senior Cafe

    Meals are available to guest 60 years of age or older for a suggested $3 per meal.  No guest will be turned away for inability to pay for a meal.

    Guests under 60 years of age can purchase a meal for $5.50 per meal.


  13. Senior Cafe Sites

    If you are going to be attending Senior Cafe Programs, please check all sites you plan to attend.

  14. MEALS ON WHEELS/HOME DELIVERED MEALS

    Meals on Wheels/Home Delivered Meals are available to guest 60 years of age or older that qualify for home delivered meals.  Meals are available for a suggested $3 per meal.  No guest will be turned away for inability to pay for a meal.

    Guests under 60 years of age can purchase a meal for $5.50 per meal.

    Please Complete this section if you are interested in receiving HOME DELIVERED Meals.  To qualify for home delivered meals, you must be medically homebound and you must not be about to prepare meals for yourself or have someone who is able and willing to prepare daily meals for you.

    **Please note that additional paperwork may be required by the Home Delivered Meal Program that is responsible for providing your meals.  You meal provider will contact you before any meals will be delivered.

  15. What types of meals are you interested in receiving?

    Please check all that apply.

  16. What days of the week do you need meals for?

    Please check all days that you wish to receive meals for.

  17. Meals on Wheels/Home Delivered Meal Programs

    Using the link above determine which program provides services in your area and check the appropriate checkbox.

  18. REFERRAL INFORMATION

    Please complete this section if you are referring a client to the Washtenaw County Meals on Wheels Program.

  19. Leave This Blank:

  20. This field is not part of the form submission.