New Client Enrollment Form

New Client Enrollment

You only need to complete this form once. If any of your personal information changes, you may email or call ACT directly to get it changed in our system.
Name

First NameLast Name
Date of Birth

MonthDayYear
Contact Number:
Format: (000) 000-0000.
E-mail
example@example.com
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
In case of emergency
Emergency Contact:

First NameLast Name
Relationship
Contact Number
Format: (000) 000-0000.
Type of vehicle needed for your transports
Use a cane, walker, rollator or other mobility assistive deviceUse oxygenNeed help getting in/out of vehicle (sedan transport)Need help getting from door to vehicleA family member or personal assistant will come with meVisual impairment - need assistanceBalance impairment - need assistanceCognitive impairment/Dementia/Gets confused easily
Is there anything else you would like us to know in order to help you have a safe, comfortable experience? (ie - unsteady walking, need help on steps, park in back of house).
Wheelchair Transports

Please provide the following information so we may send the appropriate vehicle for your needs.
YesNo
Weight (pounds)
Height (inches)
Width of wheelchair wheels (outside measurement, including push rings)
Van ramp can accommodate wheelchairs no more than 28.5 inches wide
Details that are unique to your wheelchair we need to accommodate for (ie - motorized, tilt chair, travel chair, 3-wheel scooter).
I agree to abide by the Terms and Conditions set forth by Accessible Care Transport, Inc. pertaining to passenger expectations and payment for services.

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New Client Enrollment

Wheelchair Transports