Black & White Transportation

LUCAS COUNTY SENIOR TRANSPORTATION PROGRAM APPLICATION FOR SERVICE
Required Elements:
Name: Last: First: Initial: Suffix:
Street Address: City: Home Phone: Email Address: Gender? Male Female	Apt./Lot #: State: Zip: Cell Phone: Birth Date (MM/DD/YYYY): Social Security # (Last 4 digits only):
Emergency Contact: Name Telephone:
Do you have a disability? Yes No Will someone accompany you for assistance? Yes No Do you have any medical conditions we should be aware of? Yes No If Yes, please list:	Do you use? Wheelchair Walker Cane Oxygen Other None
For demographic purposes only:
Number of persons in your household? What is your monthly income from all sources? If more than one person in the household, what is the total household income?	Race/Ethnic Info: American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White
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 Name: Driver's License/State ID Number: (In lieu of a signature, please enter your driver's license or state issued ID number in the box above to signify that you agree to the statements above.)