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About
Our Staff
Programs
Meals and Nutrition
Activities & Wellness
Get Involved
Donate
Volunteer
Blog
Orangeburg County Meals on Wheels Program
Client Eligibility Form
Contact Us
Name:
Phone:
Date of Birth:
Address:
City, State, and ZIP:
County:
Emergency Contact & Phone:
Homebound:
Yes
No
Type of client:
Waiting List
Emergency
Presumptive Eligibility
Referring Agency:
Aiken COA
Allendale OOA
Bamberg OOA
Generations
Calhoun COA
Orangeburg COA
Help at Home
LSCOG
Group Dining:
60+
Special Eligibility
Transportation:
60+
No Transportation
Special Eligibility
Evidence Based Programs
60+
Check ALL that apply (must have a risk score of 6 or higher):
Illness or condition that has changed the amount of food they eat (2)
Eats fewer than 2 meals a day (3)
Eats few fruits or vegetables (2)
3 or more alcoholic beverages a day (2)
Tooth or mouth problems (2)
Doesn't have enough money to buy food needed (4)
Eats alone most of the time (1)
3 or more prescriptions per day (1)
Lost or gained 10 pounds in 6 months (2)
Physically unable to shop, cook or feed self (2)
Total points:
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