New Client Registration

Client's Name*

First Last

Phone Number*

Email Address

Address*

Street Address Address Line 2 City State ZIP Code

Gender*

Male
Female

Date of Birth*

Ethnicity*

American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White or Caucasian

Please select one or more ethnicity you identify with. This information is collected anonymously and is only used for grant reporting to our funders.

Household Monthly Income*

Private pay is offered on a sliding scale based on income. This information is collected anonymously and used only for grant reporting to our funders.

Will you be accompanied by a service animal?*

Yes
No

Do you use a mobility aide?*

Yes
No

Type of mobility aide?*

If you use a wheelchair or scooter, is your combined weight (you and the wheelchair/scooter) more than 600lbs?*

Yes
No

If yes, what is the combined weight?*

Any conditions the drivers should be aware of? (ex. fall risk, seizures, vision or hearing loss)*

Insurance Provider*

Anthem, CareSource, PHP, etc.

Insurance Type*

Other Insurance Type*

Medicaid Number*

Emergency Contact Name*

First Last

Emergency Contact Phone*

Relationship to Emergency Contact*

Emergency Contact Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Emergency Contact Email

Are you the client?*

If you are not the client, what is your relationship to client?

Is there any other information you would like us to know?

Consent*

I agree to the privacy policy.

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