NEW CLIENT APPLICATION

Name

First NameLast Name

Date of Birth

Date

Home Phone

Please enter a valid phone number.

Cell Phone

Please enter a valid phone number.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

County

Physical Address (if different)

Town

Marital Status

MarriedWidowedSingle

SSN*

Race

Gender

What insurance coverage do you have?

FidelisMedicaid

Medicaid Cin#

Do you need assistance getting in/out of you home or doctors office?

YesNo

Do you have other transportation available to you (other than our service)?

Personal VehicleBusFamily/FriendsTaxis

Do you use:

wheelchairwalkercane

Do you need assistance getting in/out of the car?

YesNo

Where are interested in being transported?

example: doctor, work, grocery, etc...

Are you or your partner a Veteran?

What is your monthly income?

Below $931$932+

Are you a smoker:

yesno

Emergency Contact

Phone Number

Please note that the Volunteer Transportation Center does not discriminate. The eligibility of each client for the Project Wings, Persons with Disabilities, and Other Transportation programs is not based on race, color, creed, religious beliefs, sexual orientation, or age, but is based on need. The Senior Transportation Program is made possible by funding from the New York State Office for the Aging, Title III of the Older Americans Act for persons 60 years of age or older. This program does not discriminate. I will not hold any volunteer driver nor the Volunteer Transportation Center’s staff and/or Board of Directors responsible for any injury to the above-named client that occurs during the course of transportation, destination, and return home. This also includes returning the client home while noting that no other individual is at the home destination to oversee this client. Initials

Signature

Date

Relationship to client:

Phone Number

Please enter a valid phone number.

NEW CLIENT APPLICATION

APPLICANT INFORMATION (MUST BE COMPLETED BEFORE FIRST TRIP WITH VOLUNTEER)