SeniorRides+

Please fill out the CLIENT APPLICATION before filling out this form.

Email(Required)

Best CELL PHONE number(Required)

Please give us the names of the people joining you.(Required)

Date of appointment(Required)

Date of OUT OF COUNTY event or appointment(Required)

What airline will you be flying with?(Required)

Date of flight(Required)

Date of RETURN flight(Required)

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.

Signature(Required)

The Senior Connection will begin offering a GUARANTEED round trip to airports and to medical appointments, with a fee.

Senior Rides + INQUIRY form