County Longford Social Service Council CLG

Tel: No. 043.335011 / 3350138						c/o St Joseph’s Care Centre, 
Fax: No. 043.3332110							Dublin Road, 	    
Email: longfordmealsonwheels@gmail.com					Longford, Co. Longford
www.mealsonwheelslongford.ie

REQUEST FOR MEALS ON WHEELS

TEL: 043.3350114/3350138
FAX: 043.3332110

NAME				____________________________________________
							                   
ADDRESS:			____________________________________________

EIRCODE:			____________________________________________

TEL:				____________________________________________

DATE OF BIRTH		____________________________________________

REQUESTED BY & Tel No.	____________________________________________

SPECIAL DIET or Allergies	____________________________________________

REASON FOR MEALS:		____________________________________________

Emergency contact Names(s)1._______________________________Tel; ___________________

				2._________________________________Tel:___________________

Dr.	If KNOWN 		____________________________________________

DURATION:			____________________________________________

DATE:				_____________________________________________

I consent to the use of the information supplied for Meals on Wheels purposes and I will inform Co Longford Social Services CLG of any change to my personal data/circumstances.

Signature of Applicant         ……………………………………………..	(Required)

         Is a Microwave available?  Yes/No    If not we can provide at a cost of €70      
Please return to Social Services Office, Flat 6, St. Joseph’s, Care Centre, Dublin Road, Longford once completed.