CLIENT APPLICATION

NEW CLIENT APPLICATION
APPLICANT INFORMATION (MUST BE COMPLETED BEFORE FIRST TRIP WITH VOLUNTEER)
Date of Birth*

MonthDayYear
Date
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Name*

First NameLast Name
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
County*
Mailing Address (include street, city, state, zip code)*
Physical Address (if different)
Town*
Marital Status*

MarriedWidowedSingle
Who do you live with?*

RelativesNon-RelativesSelf
SSN*
Race
Gender*
What insurance coverage do you have?*

FidelisMVPTricareVNAAARPUnited HealthcareOther
Medicaid Cin Number
Complete only if you have Medicaid coverage.
Medicare Number
Do you have other transportation available to you (other than our service)?*

Personal VehicleBusFamily/FriendsTaxis
What is your monthly income?*

Below $931$932+
Are you a smoker:*

yesno
Do you use:*

wheelchairwalkercanenone
If you use a wheelchair, is there a wheelchair ramp at your home?

yesno
Are you or your partner a Veteran?
Are you able to manage 3 stairs on your own?*

yesno
Are you able to walk from your house to the car without assistance?*

yesno
Which vehicle fits you best?*

sedanSUVtruckwheelchair accessible van
Emergency Contact

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Client*
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*

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Name if not the client
Should be Empty:

NEW CLIENT APPLICATION

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