Client Application For Services 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 YouName * Required First Middle Last Date of Birth * RequiredMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Email Address * Required Address * Required Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code **Please note that we can only provide service to residents of Montgomery County, Maryland.**Best Phone to reach you * RequiredBest Evening Phone NumberCell PhoneEmergency Contact InfoName * Required First Last Relationship * RequiredAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Best Phone * RequiredEmail Referred ByName * Required First Last Organization * RequiredBest Phone * RequiredEmail * Required 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 * Required SeniorRides – escorted transportation service Pantry Fillers ‐ grocery shopping transportation assistance for those of lower income Friendly Calls -- a volunteer calls the client to check in Demographics Gender * RequiredMaleFemalePrimary Spoken Language * RequiredEnglishEthnicity Self-Identified As * Required Asian/Pacific Islander American Indian/Alaskan Hispanic Black/Not Hispanic White/Not Hispanic Multi‐racial Other Current Living Arrangements * Required Alone‐Private Residence Alone‐Group Residence Lives with Spouse/family Lives in Assisted Living Do You Have Pets? * RequiredNoYesDo You Have Pets? Specify Type/BreedDo You Smoke? * RequiredNoYesPlease check the box that best describes your annual income level.Income Status: * RequiredIndividualCoupleIndividual * Required $31,225 per year or less $31,226 ‐ $49,959 per year Over $49,960 per year Couple * Required $42,275 per year or less $42,276 ‐ $67,639 per year Over $67,640 per year Mobility Issues & DevicesCheck all that may affect your mobility * Required 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 * RequiredPlease indicate all assistive mobility devices you use * Required 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 abovePantry Fillers OnlyIncome Source - #1AmountIncome Source - #2AmountIncome Source - #3AmountIncome Source - #4AmountIncome Source - #5AmountTotal Annual IncomeI 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 * Required**Use your mouse, touch screen or touch pad to add your signature.Date of Signature - must be mm/dd/yyyy format * Required Date Format: MM slash DD slash YYYY 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 * Required I have read and agree to all terms and conditions detailed within this application.Client Signature * Required**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.