Washtenaw Community Programs Referral Form

Washtenaw Community Programs Referral Form
ATTN: SUBMITTING A SECOND REFERRAL FORM WILL DELAY YOUR PROCESSING. IF YOU HAVE ALREADY SUBMITTED A FORM AND HAVE QUESTIONS, CALL 734-259-4125.
Community Details
What Program Are You Referring For?*
Age of Rider*

55-5960+
IMPORTANT:

While we encourage you to complete the referral today, please know that the program has reached capacity for fare-free rides for individuals 60+ at this time.

We will contact you as soon as capacity opens up.

Thank you for your patience and understanding.
Rider Details
Name*

First NameLast Name
City State Zip*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
City
State
Zip Code
Rider Phone Number*
Please enter a valid phone number.
Rider Email
example@example.com
Will the individual require translation/interpretation services?*

YesNo
Preferred Language if English is not their first language
Preferred Language if English is not their first language
Will the individual be using a caregiver/loved one to interpret their answers?*

YesNo
Age of Individual
Is a car seat needed for the infant?

YesNo
Age of Individual*

18+
What relationship do you have to the individual?*

The individual is a client/patient/program participantThe individual is a family member/friend/receives care from meI am referring myself
Referring Organization
Name of Person Making Referral*

First NameLast Name
Title
Organization
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Referring Individual - Caregiver/Family Member/Friend
Name of Person Making Referral*

First NameLast Name
Relationship to the Individual
Primary Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Notes About Referral: Mobility Needs/Trip Purposes/Health Concerns*
I understand that the fare-free program is currently at capacity, and I have been added to the waitlist. I also acknowledge that there is no specific timeframe for when I will be able to enroll in the program.*

Yes
Should be Empty:

Washtenaw Community Programs Referral Form

Community Details

IMPORTANT:

Rider Details

Referring Organization

Referring Individual - Caregiver/Family Member/Friend