Private Pay Meals Application
Recipient's First Name:
Year of Birth:
Number, Street, Town
**Please note that in most cases it may not be safe to serve the program's regular meals
to a person with a life-threatening food allergy due to the risk of unknown ingredients and
cross-contamination. Highland Valley Elder Services may not fulfill requests based on
reported food allergies.
Meal Selection: please select the type of meal and the meal schedule below:
Hot Lunch Meal
Frozen Supper Meal
Frozen Meals for
If you are not home to receive your meal delivery, someone must be home to receive the meal
for you, as food cannot be left unattended. If the door is not answered for the meal(s), Highland
Valley Elder Services follows a well-being check procedure, to ensure that you are safe. This
includes calling you, your emergency contacts, local hospitals, and ultimately calling emergency
services in your town if we cannot reach you. Well-being checks are a requirement through the
Federal Home Delivered Meals program, but can be waived for those receiving Private Pay Meals.
By checking this box, you are WAIVING the well-being safety check:
By signing this document, you are agreeing to enroll in the Private Pay Meals Program, with the
meal schedule as indicated above. Prices for private pay meals are subject to change. You will be
informed sixty (60) days in advance of pricing changes, via the email or address provided on this
application. This is a voluntary program and participants can choose to dis-enroll at any time by
calling the phone number on the menu associated with your town. If at any time you feel you
meet the criteria for the Federal or state home delivered meals program, such as being over 60
years old, homebound, not capable of making meals independently, and/or you enroll in a State
Home Care Program, please call Highland Valley Elder Services 413-586-2000 to request a review
to see if you qualify for meals at no cost.
Information on meal cancellations and other policies for the program will be provided with the
first delivered meal. Once your initial payment is received and processed, you will receive a phone
call to confirm the date your meals will begin (approximately three days after payment clearing).
Consumers are required to cancel meals at least 48 hours in advance of a scheduled delivery by
calling the dining site associated with their town. Consumers will be responsible for payment of
meals that are not cancelled according to these guidelines. If payment is not made, meals will
cease immediately and will remain suspended until the balance is paid. If your meals are
suspended for over thirty (30) days, a refund check will be issued.
If you have any questions, please reach out to our Information & Referral Team: 413-586-2000.
Signature of Applicant:
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