New Subscriber Questionnaire

Meals on Wheels Shaker provides a low cost meal delivery service to the community members of Shaker Heights, Beachwood, University Heights and parts of Warrensville Heights. The service area includes the following zip codes 44118, 44120, 44122 and 44128, all within a four-mile radius of our commercial kitchen facility at 21600 Shaker Blvd., Shaker Heights, OH 44122.

If you do not receive a response within 48 hours, please call (216) 991-6376. This form does not work with all browsers. Someone will contact you to discuss your answers.

* Indicates required field

Start Date *

How did you hear about us? *

Subscriber Information:

Name *

First

Last

Date of Birth *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Instructions for Delivery Driver (food will not be left unless you have a cooler) *

Phone Number *

Cell Phone Number *

Email *

Additional Emergency Contact:

Name *

First

Last

Relationship to Subscriber *

Phone Number *

Cell Phone Number *

Email *

Billing Information:
A $50 security deposit is required

Who is responsible for payment *

Preferred method of billing (select one) *

Food/Meal Information:

Are You diabetic? *

Yes No

Food allergies *

Beverage (select one) Each beverage will cost an additional $.50. *

Dessert (select one) *

Any other information that will help serve the client better *

Submit