JOIN THE TEAM
APPLICATION FOR SERVICE
Lucas County Senior Transportation Program
Birth Date (MM/DD/YYYY)
Social Security # (Last 4 digits only)
Do you have a disability?
Do you use?
Will someone accompany you for assistance?
Do you have any medical conditions we should be aware of?
If Yes, please list
(for demographic purposes only)
American Indian or Alaska Native
Black or African American
Native Hawaiian or Other Pacific Islander
What is your monthly income from all sources?
Number of persons in your household?
If more than one person in the household, what is the total household income?
To the best of my knowledge, the information provided in this application is correct.
I agree to receive services under this program and under the terms of the program.
In the event of a medical emergency, medical information may be provided to emergency responders.
I understand that any client information obtained is confidential and no personal identifying information will be released without my written consent unless otherwise required by federal law.
Full Legal Name
(In lieu of a signature, please enter your full legal name in the box above to signify that you agree to the statements above.)
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