Client Application

Name

First NameLast Name

Preferred Name

I wish to be called

Date of Birth*

mm/dd/year

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Gender

Hispanic

Marital status

SingleMarriedDivorcedWidow

My Race is*

Ethnicity*

I need help with: (suggested voluntary contributions are listed below)

My #1 need is:*

I need services to start: (list date below)*

I use

Wheel chairWalkerOxygenOther

Check ALL that are true*

My insurance information*

What else would you like us to know?

How did you hear about us?*

Emergency Contact*

Becoming a member is free of charge. If you would like to support our efforts to provide services to older adults in our community, we welcome optional donations. A contribution of $25 helps cover the cost of onboarding a new member like you, and $50 covers you and another member. Your membership is always welcome, whether or not you choose to make a donation! Upon submitting your application, you will have the opportunity to donate on the next page. Thank you!

Onboarding Donation

USDAmount

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

I acknowledge that my participation in the Aging Resources of Douglas County (ARDC) volunteer program is voluntary. And by participating, I release ARDC, its staff, board of directors, associates, clients, and volunteers from any liability for any injuries, medical expenses, or damages related to services provided by ARDC and its volunteers. I also agree to follow the volunteer program rules and guidelines. The decision to admit members into the program and provide transportation is at the sole discretion of ARDC. ARDC ensures that no one is excluded from participating or benefiting from its services based on race, color, sex, age, religion, marital status, or sexual orientation.
By submitting my application, I confirm that I have read, understand, and agree to comply with the Member, Policy, Rights & Protection Agreement.
I grant ARDC permission to use quotes and/or photos of me for marketing purposes.

I have read and understand the above statement and attest that this application has been filled out in its entirety by me or under the power of attorney. By signing, I fully agree to all terms.

Electronic Signature (type your name to sign)*

Your service is partially funded by state and federal grant monies and volunteer help. Contributions are welcome. Any amount will be used to expand services. Your decision to contribute or not is kept confidential. Services will not be denied if you are unable or choose not to contribute.