FRIENDSHIP TRAYS
Prospective Recipient Information

Thank you for providing below the requested information on the person you think might need nutritious meals delivered to the home Monday through Friday.

Below, there are some check boxes seeking your judgment of the prospective recipient's condition. Thank you for making those judgments and checking the most appropriate box. Your answers would never be used as sole grounds for refusal of service. Instead, this detailed information helps our small staff expedite a decision. Fill in all the information you can. Submit the form even if you can't answer every question.

When you click the "Submit" button at the end, the information you have provided is compiled into an e-mail and is sent to Intake Coordinator Annie Cotten at Friendship Trays. If you would prefer to send us the information in another way, you may type the information on a form downloaded into your computer. You would then print out the form and either fax it to us or mail it. A link to that paper form is at the bottom of this page.

Please put your cursor in the first field below where you type. Once your cursor is in a field, you may use the Tab key on your keyboard to move from field to field.

 

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Part One: About the person filling in this form:

 

Name:

Your e-mail address:

Your phone:

Relation to prospective recipient:

 

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Part Two: About the person to be served by Friendship Trays:

Name:

Birthdate:

Street address:

ZIP code:

E-mail (write none if NA):

Doctor's name:

Doctor's phone:

Doctor's fax:

Known medical conditions:

Known food allergies:

Special diet needs:

Resides: Alone With family With one other person

Has access to: Conventional oven Microwave

Vision: Good Fair Poor

Hearing: Good Fair Poor

Dental: Has own teeth Dentures

Now eats mostly soft foods: Yes No

Mental status (you may check more than one):

Alert   Oriented   Depressed   Alzheimer's   Confused   Forgetful   Difficult

Other comments:

 

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Part Three: Emergency contacts for person to be served by Friendship Trays:

 

Contact 1:

Address: City: State: ZIP:

Relation to prospective recipient:

Phone   Pick One: Home Work Cell     

Phone   Pick One: Home Work Cell   

 

Contact 2:

Address: City: State: ZIP:

Relation to prospective recipient:

Phone   Pick One: Home Work Cell     

Phone   Pick One: Home Work Cell   

 

Please check this box to prepare your form for delivery.

Thank you so much for letting us know of this need in our community!   

 

For the paper form, click here.