| Meals on Wheels Diablo Region

Request a Speaker

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Name of Organization

Location of Meeting

Preferred Dates and Times

Event Start Time

Hour

:

Minute

am

pm

Speaking Start Time

Hour

:

Minute

am

pm

How long would you like the presentation to be?

Organization Website

Name of Contact Person

Address

Phone Number

Email Address

Read more about Request a Speaker

Friendly Programs Client Application

1 Start 2 Complete

Friendly:

Visitors

Callers

Helpers

If you are completing this form for another person, please include your name and number

Name

Phone

Client Information

Date *

Month

Day

Year

Last Name *

First Name *

Date of Birth *

Month

Day

Year

Address *

City, State, Zip *

Phone *

Alternate Phone Number

Do you have voicemail?

Yes

No

Can you send and receive test messages?

Yes

No

Preferred Language

Second Language

Email

Veteran:

Yes

No

Marital Status

Gender:

If not listed, please specify

Sexual Orientation or Sexual Identity:

Not listed, please specify

Ethnicity:

Race:

Please specify if not listed

Approximate total monthly income

Cal-Fresh Recipient:

Yes

No

Current Support System (friends, family members, care givers, etc)

Emergency Contact

Name

Relationship

Address

Phone

Email

Mobility:

Hearing

Hearing Issues

Able to hear over the phone?

Yes

No

Vision

If low vision, describe here:

Memory

Memory Issues:

Yes

No

If yes, describe:

Other Health Issues/Conditions/Limitations:

Are you driving?

Yes

No

Are there smokers in the home?

Yes

No

Do you receive Meals on Wheels?

Yes

No

Would you like information on Meals on Wheels?

Yes

No

Would you like information on Fall Prevention?

Yes

No

Other:

About You

Tell us a few things you enjoy doing:

Tell us a few things you like to talk about:

Do you prefer a man or a woman visitor, or no preference?

Man

Woman

No Preference

Would you consider a volunteer who visits with children?

Yes

No

Any other details to help us find a compatible volunteer for you? *

Read more about Friendly Programs Client Application

Home Safety Modification Form

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Referral From

Organization

Email

Phone

Date Submitted

Month

Day

Year

Client Information

First Name

Last Name

Street Address

City

State

ZIP Code

Preferred Phone Please add dashes

Preferred Email

Best time to reach client?

Hour

:

Minute

am

pm

Gender

Male

Female

Marital Status

Married

Single

Date of Birth

Month

Day

Year

Family member to contact?

Phone number

Care Giver's Information

Name

Care Giver Phone

Relationship

Screening Questions

Exercise

Is the client exercising?

Yes

No

Duration and frequency of exercise?

Interest in in-home exercise program?

Yes

No

Client Care

Other fall prevention programs available to client

Yes

No

What other agencies are involved in client's care? (ex: Home Health, IHSS, unknown)

Read more about Home Safety Modification Form

Sign Up to Volunteer

Contact Information

First Name *

Last Name *

Employment Status

Employer/Retired From

Group affiliation (if applicable)

Street Address *

City *

State *

ZIP Code *

Preferred Phone (a mobile phone is required for our Meals on Wheels volunteer drivers) *

Please input your phone number in this format: (000) 000-0000

Email *

Program Interest

Which volunteer programs and opportunities are you interested in?

Other

Personal Interest

How did you hear about MOWDR?

Emergency Contact Information

Name

Relationship

Phone

Please input your phone number in this format: (000) 000-0000

Screening Questions

When a volunteer has access to confidential information (Meals on Wheels program, Fall Prevention, Office Volunteer) or visits a senior in their home (Friendly Visitor Program), a background check is required. Our volunteer screener, Sterling Volunteers, requests a $22.50 fee to cover the cost of a background check. You have a choice to cover the cost of the screening - either in part or in full - off-setting this expense for MOWDR. If you do not choose to cover this charge, it will be absorbed by MOWDR. I am willing/able to make this donation: *

Yes

No

I am in good health and free of communicable diseases: *

Yes

No

Have you ever volunteered before? *

Yes

No

If yes, where

I am a US citizen: *

Yes

No

Level of Education *

My first language is: *

Other Languages?

Read more about Sign Up to Volunteer

Contact Us

Salutation *

First Name *

Last Name *

Phone

Email *

Street Address

Address Line 2

City

State

ZIP Code

How did you hear about us?

Specify Other *

Subject *

Message *

CAPTCHA

This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.

Read more about Contact Us

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