Workers on Wheels - Sign Up
Sign up to receive rides through the Workers on Wheels program by Active Generations to receive rides to medical appointments and to get groceries within the Sioux Falls area.
Are you completing this sign up for yourself or for someone else?
*
Myself
On behalf of someone else
Referrer Information:
Referrer Name
*
First Name
Last Name
Referrer Organization
Referrer Phone Number
*
Format: (000) 000-0000.
Referrer Email
*
Participant Information:
Name
*
First Name
Last Name
Home Address
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Unit / Suite
If Applicable
Phone Number
*
Format: (000) 000-0000.
Email
Demographic Information:
Date of Birth
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-
Month
-
Day
Year
Gender
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Female
Male
Them / They
Other
Prefer Not to Answer
Did Not Ask
Race
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White / Caucasian
Native American
Black / African American
Native Hawaiian / Pacific Islander
Alaskan Native
Asian
Multi-Racial
Other
Prefer Not to Answer
Did Not Ask
Ethnicity
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Hispanic / Latino / Spanish
Not Hispanic / Latino / Spanish
Prefer Not to Answer
Did Not Ask
Language Spoken
*
Please Select
English
Spanish
Nepali
Swahili
Kuanyama
Amharic
Other
Other Language Spoken
*
Hospital Preference
*
Sanford
Avera
Falls Community Health
Veteran's Administration
Other
Unknown
Emergency Contact:
Emergency Contact Name
*
First Name
Last Name
Relationship
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What is your emergency contact's relationship to you?
Emergency Contact Phone Number
*
Format: (000) 000-0000.
What is your mobility level?
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No Help Needed
Needs Assistive Equipment
Other (Detail Below)
Assistive Device Description / Medical Concerns / Special Needs
Examples: Wheelchair, Walker, Cane, Diabetic Medications
Do you currently receive Meals on Wheels?
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Yes
No
Would you like to receive more information about Meals on Wheels?
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Yes
No
Submit
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