Surrey/North Delta Meals on Wheels

REGISTER

To register for meal delivery, you can either:

contact us by telephone 778-590-1433 and provide the information below, or
download, print, fill-out and fax the registration form to 778-590-1434, or scan and e-mail it to sndmow@telus.net, or
complete the form below and press the Submit button at the bottom of the form to register on-line.

We will be in touch shortly to confirm your registration and payment arrangements.

Client Information

* required fields

Name *

Home Address *

Apt No.

Buzz No.

Street Address

City

Postal Code

Special Delivery Instructions, Directions

Home Telephone *

Email Address *

Date of Birth *

Start Date *

Special Dietary Needs

Family Contact or Emergency Contact

Name *

Relationship *

Home Address *

Apt No.

Street Address

City

Province/ State

Postal Code

Home Telephone *

Work Telephone

Sponsor (if someone other than the client is paying for the service)

Name

Home Address

Apt No.

Street Address

City

Province/ State

Postal Code

Home Telephone

Work Telephone

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