FAIRBORN SENIOR CENTER
325 N. Third St. Fairborn, Ohio 45324
PRIORITY POLICY, STATEMENT OF NEED FOR SERVICES, PARTICIPATION AGREEMENT
(This Form Must be Signed by the Requesting Client or Designated Representative)
I am requesting services from the Fairborn Senior Citizens Association Transportation Service Department.
I understand priority will be given to clients requiring medical appointments, clients 75 years of age and older, and disabled clients.
I understand that the transportation service has certain risks and hazards inherent with the mode of travel and to places to which I travel. These risks include but are not limited to, motion sickness, tripping and/or slipping and falling on curbs, steps, stairways, ramps and motor vehicle accidents.
I also understand and agree to follow the instructions given by the Transportation Coordinator and/or driver and agree to follow all rules and regulations of the Transportation Service Department and the Fairborn Senior Citizens Association as they apply.
When completed, submit this form to the Transportation Coordinator!