Apply for Senior Services in Montgomery County

All sections MUST be completed when applying for services. By submitting this application, you are agreeing to the terms and conditions detailed within. All information is kept strictly confidential.

About You

Name*

First Middle Last

Date of Birth*

Email Address*

Address*

Street Address Address Line 2 City State ZIP Code

**Please note that we can only provide service to residents of Montgomery County, Maryland.**

Best Phone to reach you*

Best Evening Phone Number

Cell Phone

Emergency Contact Info

Name*

First Last

Relationship*

Date of Birth*

Address*

Street Address Address Line 2 City State ZIP Code

Best Phone*

Email

Referred By

Name

First Last

Organization

Best Phone

Email

Services You Are Applying to Receive

(Please note that restrictions may apply and not all applicants will qualify for all services and/or programs. If there are any concerns, we will contact you to find a solution.)

Services Interested In*

SeniorRides – escorted transportation service
Pantry Fillers ‐ grocery shopping transportation assistance for those of lower income
Outdoor Excursion Trips

Demographics

Gender*

Male
Female

Primary Spoken Language*

English

Ethnicity Self-Identified As*

Current Living Arrangements*

Alone‐Private Residence
Alone‐Group Residence
Lives with Spouse/family
Lives in Assisted Living

Do You Have Pets?*

No
Yes

Do You Have Pets? Specify Type/Breed

Do You Smoke?*

No
Yes

Please check the box that best describes your annual income level.

How many people live in your household?*

Income level*

$15,650 per year or less
$15,651 - $21,150
$21,151 - $26,650
$26,651 - $32,150
$32,151 - $37,650
$37,651 - $43,150
$43,151 - $48,650
$48,651 - $54,150
$54,151 per year or more

Mobility Issues & Devices

Check all that may affect your mobility*

Respiratory or breathing problems
Impaired vision
Stroke/paralysis
Broken bones or sprains
Impaired hearing
Memory loss
Dizzy spells
Other
N/A

Check all that may affect your mobility - Other*

Please indicate all assistive mobility devices you use*

Canes
Service Animal
Walker
Wheelchair*
Other
N/A

*Currently, we cannot accept clients using wheelchairs unless they are able to transfer to and from a vehicle with minimal assistance. We cannot transport wheelchairs of any kind.

Other assistive mobility device not listed above

Pantry Fillers Only

Income Source - #1

Amount

Income Source - #2

Amount

Income Source - #3

Amount

Income Source - #4

Amount

Income Source - #5

Amount

Total Annual Income

I declare under penalty of perjury that all the income and asset information provided herein is true and correct to the best of my knowledge and belief. I understand that untruthfulness or misleading answers are causes for rejection of this application. I understand that I may be required to provide additional documentation to qualify for certain services.

Client Signature/Signer's Name Completed on Behalf of Client*

**Use your mouse, touch screen or touch pad to add your signature.

Date of Signature*

Completed by on behalf of client

First Last

**If you complete and submit this on behalf of an applicant, you agree that you have discussed with, and the applicant fully understands, all terms and conditions listed in this application/service agreement.

Senior Connection provides services for eligible seniors in Montgomery County, MD, and reserves the right to determine client eligibility. Clients agree to be bound by the service descriptions provided by the Senior Connection and agree to the following guidelines of participation:

CLIENTS CODE OF CONDUCT – All clients agree to:

Call the office for all service requests. Do NOT contact the volunteer directly.
Abide by the program policies and restrictions.
Notify the office of any ride or service cancellations as soon as possible. Excessive cancellations may result in dismissal from the program.
Be prepared to depart at the requested pick‐up or scheduled service time.
Be mentally alert and prepared for your service.
If you are ill, call the office to cancel/reschedule your ride. Drivers have the right to decline to take you if you appear ill upon their arrival.
Be courteous to your volunteer and follow their instructions at all times.
Be ambulatory or able to self‐transfer into and out of the vehicle.
Pay for any parking, tolls, groceries, prescriptions or other items you acquire during service.
Contact the office immediately if there is a problem or concern.

CLIENT AGREEMENT

I hereby certify that all information I have supplied in this client application is true, complete, and accurate. I understand that by submitting this application, I authorize inquiries to be made concerning my suitability as a client and that this application is not a guarantee that I will be accepted as a client with the Senior Connection. I hereby affirm that I meet all minimum requirements for the program(s) I am applying for and have provided such additional information as required. I agree to comply with and be bound by the policies of the program. Furthermore, I agree that the Senior Connection may, for publicity and other purposes, use my image and/or any comment or quotation made by me.

I understand that the Senior Connection may collect medical information from me that may include diagnosis, symptoms, treatments, doctor visits or other similar information. Any such information provided is strictly confidential and will not be disclosed or used for any purpose other than providing such services as requested herein.

I also understand and agree that for any service performed for me which includes any period that I am under general anesthesia (or similar), it will be my sole responsibility to have assistance available for me by a third party. Any responsibility of the Senior Connection, its staff and volunteers ends when the scheduled transportation appointment is concluded and I am delivered to my residence.

I hereby release, waive, indemnify and hold harmless the Senior Connection, its Directors, Officers, employees and volunteers from any and all loss, damages or liability including personal injury or death arising from my voluntary participation in the program(s) to which I have applied. I further agree that this Client Agreement and Waiver of Liability is intended to be as broad and inclusive as is permitted by the laws of the State of Maryland, and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

I have read and voluntarily sign this Client Agreement and Waiver of Liability. I do so, recognizing that I have been advised by Senior Connection that I have the right to consult with my own legal counsel concerning this Client Agreement and Waiver of Liability for clarification of any of the terms contained herein. I further agree that no oral representations, statements or inducements, apart from the foregoing written agreement, have been made.

Consent*

I have read and agree to all terms and conditions detailed within this application.

Client Signature/Signer's Name Completed on Behalf of Client*

**Use your mouse, touch screen or touch pad to add your signature.

Completed by on behalf of client

First Last

**If you complete and submit this on behalf of an applicant, you agree that you have discussed with, and the applicant fully understands, all terms and conditions listed in this application/service agreement.

Consent*

I understand that rides are NOT guaranteed.

Number