One uni test page - Senior Connection

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.

THIS APPLICATION IS ONLY FOR ONE UNIVERSITY BUILDING RESIDENTS! ALL ONE UNIVERSITY BUILDING RESIDENTS MUST FILL OUT THIS FORM TO BOARD OUR BUSES!

About You

Name

First Middle Last

Date of Birth

Email Address

Address

Street Address Address Line 2 City State ZIP Code

Best Phone to reach you

Emergency Contact Info

Name

First Last

Relationship

Address

Street Address Address Line 2 City State ZIP Code

Best Phone

Email

Demographics

Gender

Male
Female

Primary Spoken Language

English

Ethnicity Self-Identified As

Asian/Pacific Islander
American Indian/Alaskan
Hispanic
Black/Not Hispanic
White/Not Hispanic
Multi‐racial
Other

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.

Income Status:

Individual
Couple

Individual

$36,450 per year or less
$36,450 ‐ $51,030 per year
Over $58,320 per year

Couple

$49,300 per year or less
$49,300 ‐ $69,020 per year
Over $78,880 per year

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

Senior Connection provides services for eligible seniors and reserves the right to determine client eligibility. Clients agree to be bound by the service descriptions provided by Senior Connection and agree to the following guidelines of participation: Senior Connection provides services for eligible One University building residents, 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:

-Abide by the program policies and restrictions.
-Notify the trip manager 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, contact the trip manager to cancel your pick up. Drivers/volunteers have the right to decline to take you if you appear ill upon their arrival.
-Be courteous to your volunteers and follow their instructions at all times.
Be ambulatory or able to self‐transfer into and out of the vehicle.
-Pay for the trip as soon as possible. If payment isn’t received on time, your seat could be given away.
-Contact the trip manager immediately if there is a problem or concern with a service provider.

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.