NUTRITION SUPPORT PROGRAM

Program Application

Thank you for your interest in the TakeCare Nutrition Support Program. This program provides nutritious, thoughtfully prepared meals to support mothers during pregnancy and the postpartum period — so families have access to healthy food during this important stage of life.

WHO THIS PROGRAM IS FOR

Pregnant mothers
Mothers up to 12 months postpartum
Individuals enrolled in Medicaid Managed Care
Residents of Rockland County, NY

Eligibility is reviewed after submission. Submitting this form does not guarantee enrollment.

Applicant Information

Details for the person receiving meals. Household members are added further down.

First name *

Last name *

Date of birth *

Contact number *

Email *

Home Address

Street address *

Street address line 2

City *

State *

ZIP code *

Pregnancy & Postpartum

Currently pregnant? *

If postpartum, months since delivery

Medicaid

Currently enrolled in Medicaid? *

Medicaid CIN

2 letters, 5 numbers, then a letter — on the Medicaid or insurance card. Optional, but providing it expedites your application.

Medicaid plan *

Additional Household Members

Add the other household members who are active on Medicaid and will receive meals — spouse first, then children oldest to youngest. Up to 9. Do not repeat the person named above.

Food Supplies

Select the services you need (check all that apply).

Cooking suppliesMicrowaveRefrigeratorMedically Tailored Meals

Questions? Call (845) 201-9998

Submitting this form does not guarantee enrollment. All applications are reviewed to confirm eligibility based on program guidelines and availability.