Fill out the form below to provide information on the person you think may need nutritious meals delivered to their home Monday through Friday. Your best judgment with these answers helps our small staff expedite a decision.

Important: This form is only for requesting Meals on Wheels.
Do not use this application for grocery referrals. Find out how to get a referral for a week’s worth of groceries here.

If you need  immediate food assistance, please call us at  (704) 523-4333. Our team can help you get started and connect you with other resources.

"*" indicates required fields

MM slash DD slash YYYY
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Address*
Adding your email opts you in to receive news including updates about meal deliveries or cancellations and monthly invoices.
Veteran?

Emergency Contacts

Address
Address

Other Information

Dietary Needs
Resides
Has Access to
Vision
Hearing
Dental
Now eats soft foods
Mental Status
Have you received groceries/temporary food assistance from Nourish Up (formerly Loaves & Fishes/Friendship Trays) before?
This field is for validation purposes and should be left unchanged.

By submitting this form, applicant certifies that the information provided above is true and accurate to the best of their knowledge. Applicant understands that Nourish Up is not liable for any consequences arising from inaccuracies or omissions in this application.