Basic Info

Male Female
Married Widow/Widower Divorced Single
Yes No

Emergency Contact



Secondary Emergency Contact


Address

Delivery Address



Billing Address (Copy)


Options

Medical Conditions Check all that apply



Impairments


     Yes No
     Yes No
     Yes No
     Yes No
     Yes No
     Yes No

Pets


     Yes No

Information

Home Information


     Yes No
     Front Door Back Door Side Door Breezeway
     Yes No
     Yes No

Income

     0-$582 $582-786 $787-991 $992-1196 $1197-1401 $1402+
     Individual Joint
     Yes No
     Yes No
M T W Th F S

Agreement

Welcome to Meals on Wheels of Sarasota, INC

Welcome to Meals on Wheels of Sarasota’s Meal Service program. By signing below you are indicating that you wish to receive our service under the following guidelines, terms and conditions. You have contracted with us to receive meals to be delivered to you at a cost of: $4.50. This is an agreement to pay for meals prepared in our kitchen delivered via volunteer. A $50 deposit is due with your application and will be applied to your final invoice. Your invoice will be sent to you at the end of each calendar month. Payment is due upon receipt and no later than within ten (10) days. Please read the information below. We look forward to serving you. Call us at 941-366-6693 if you have questions.

Guidlines

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1. We serve lunch time meals delivered by volunteers Monday through Saturday between 11 am and 1 pm. Please be prepared to receive the delivery.
2. The food delivered is meant to be consumed within 24 hours of delivery
3. We require 2 business days cancellation notification to avoid payment.
4. You have signed authorization for us to enter your home after knocking if you cannot get to the door, either yes or no. If you do not answer, we will leave you a message that we attempted delivery and contact your emergency name to verify your wellbeing.
5. You have authorized us to leave your meal outside your door if you are not at home or do not answer the door, either yes or no, and either you will provide a cooler or have asked us to do so. Please keep the cooler empty and clean. If we notice that you need a new one, we will replace it at no cost.
6. Please keep us aware of any major changes in your medical condition.
7. Please keep us aware if you have a change in your emergency contact information.
8. If a driver reports that your meal has not been taken (if it has been left outside), we will immediately call your emergency contact. If we cannot reach your contact, we will take appropriate contact to have emergency services check on you. We are always interested in your safety and wellbeing.
9. To re-start meal delivery, please call us no later than noon the day before and ask a staff member to resume your service or leave your message on our machine.
10. If you will be out of town or require medical care for an extended period of time, we will put your meal service on temporary suspension.
11. Our drivers do not accept payment. Please mail your payment to the office.
12. I agree to pay a $25 service charge on any returned check issued as payment for Meals on Wheels service.
13. Please secure your pet during delivery tines to ensure the safety of our volunteers.
14. Please advise us of any change in address or location at your earliest opportunity.

Release and Waiver of Liability Agreement

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This Release and Waiver of Liability (the “Release”) is made and entered into effective as of July 27, 2017, by and among , (the “Participant”) and Meals on Wheels of Sarasota, a Florida nonprofit corporation, its directors, officers, employees, and agents (collectively “MOW”)

Background

MOW is a Florida non-profit organization that provides meals through the generosity of voluntary drivers for individuals in need of sustenance. By voluntarily applying to receive such voluntary services from MOW, Participant will be a client recipient of food prepared by MOW (collectively “the Activity”).

Terms

1. Background. The parties hereby agree that the above Background section is true in all respects and such Background section constitutes a material part of this Agreement.

2. Release and Waiver. Participant does hereby release and forever discharge and hold harmless MOW, its officers, directors, agents, volunteers, and its successors and assigns from any and all liability, claims, and demands of whatever kind or nature, either in law or in equity, which arise or may hereafter arise from Participant’s participation in the Activity. Participant understands and agrees that this Release discharges MOW from any and all liability or claim that the Participant may have against MOW with respect to any bodily injury, personal injury, illness, death, or property damage that may result from services provided by MOW, whether caused by the negligence of MOW or its officers, directors, employees, volunteers, agents, or otherwise. Participant also understands that MOW does not assume any responsibility for or obligation to provide financial assistance or other assistance, including but not limited to medical, health, or disability insurance in the event of injury or illness.

3. Assumption of the Risk. Participant understands that acceptance or participation in the Activity could result in bodily injury, property damage, or death. Participant hereby expressly and specifically assumes the risk of injury or harm in the Activity and releases MOW from all liability for injury, illness, death, or property damage resulting from the Activity.

4. Other. Participant expressly agrees that this Release is intended to be as broad and inclusive as permitted by the laws of the State of Florida and that this Release shall be governed by and interpreted in accordance with the laws of the State of Florida.

Participant agrees that in the event that any clause or provision of this Release shall be held to be invalid by any court of competent jurisdiction, the invalidity of such clause or provision shall not otherwise affect the remaining provisions of this Release which shall continue to be enforceable.

I HAVE READ THIS RELEASE AND WAIVER OF LIABILITY, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND HAVE SIGNED IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT, ASSURANCE OR GUARANTEE BEING MADE TO ME AND INTEND MY SIGNATURE TO BE A COMPLETE AND UNCONDITIONALRELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW.

If signed by Parent or Guardian: I verify that I have read the foregoing and that the contents of this Agreement, a description of the Activity, and possible dangers detailed herein were explained to the Participant.

**Note that if you are 60 – 80 years old and require financial assistance with meal payments we require that you register with the Elder Helpline; verification of registration with Elder Helpline is provided by their staff weekly. We allow 10 days for you to register. (866-413-5337)