The Sourcewise Meals on Wheels Program

Thank you for your interest in the Meals on Wheels program.

A nutritious diet is the foundation of a healthy lifestyle, but that’s not always easy for homebound seniors. Meals on Wheels can bring that nutrition right to your door, regardless of your economic status.

Our two daily meals are well-balanced and meet two-thirds of the daily nutritional requirements for seniors. While the meals are not specially designed for persons with diabetes or high blood pressure, they are low in sodium and sugar content.

If you are interested in the program, please fill out this brief interest form and someone from our team will contact you.

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Who are you applying for? *YourselfSomeone Else

Your Name, if applying for someone else

Phone Number, if applying for someone else

Relationship to Client? *

Please fill out the client Information below.

First Name *

Last Name *

Email

Phone Number *

Address *

Zip Code *

Would you like to receive future updates and mailings from us? *

• Yes
• No

Date of Birth *

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Sex at Birth *MaleFemalePrefer not to respond

Sexual Orientation *Straight/HeterosexualBisexualGay/Lesbian/Same-Gender LovingQuestioning/UnsureNot listed, please specifyPrefer not to respond

Please Specify *

Select your Income Level per Month: *Under $900$901 - $1,500$1,501 - $2,500$2,501 - $4,000$4,001 - $4,833Over $4,834Prefer not to respond

What language do you feel most comfortable speaking? *

• English
• Mandarin
• Vietnamese
• Spanish
• Other

Other Language

How many adults live at this household? *12345+

Do you drive? *

• Yes
• No

Do you have a caregiver? *

• Yes
• No

Have you ever served in the US military? *

• Yes
• No
• Prefer not to respond

In affiliation with someone who is serving or has served in the US military? *

• Yes
• No
• Prefer not to respond

If affiliated, would you like us to share your contact details with VA for additional assistance? *

• Yes
• No
• Prefer not to respond

Please check the services below where you would like to receive more information.

• Information & Awareness (locate resources in Santa Clara County);
• Care Management;
• Caregivers Network;
• Digital Link (iPad Technology Program);
• Health Insurance Counseling & Advocacy Program (Medicare);
• Public Authority Services;
• Senior Employment Services;
• South County Services;
• Other;

Other Services

How did you find out about this Meals on Wheels program? *Postcard in MailEmail from SourcewiseCase ManagerFriend or Family MemberSocial Media

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