Senior Citizen Food Delivery Consent Form
Personal Information
Full Name
Date of Birth
Address
Phone Number
Email Address
Emergency Contact
Contact Name
Contact Phone
Relationship
Food Preferences / Allergies
Dietary Requirements / Preferences
Allergies
Consent
I consent to the delivery of food to the address provided above. I acknowledge that I have reviewed any dietary information and understand that it is my responsibility to inform the provider of any allergies or health conditions. I consent to sharing my information with the food delivery coordinator and provider for the purpose of organizing safe delivery.
I agree to the above consent statement
Signature
Date