The following information is used to compile statistical data and is required by the government for certain funding of our programs. It is not used to determine your eligibility. Please answer all questions.
Please note that the Volunteer Transportation Center does not discriminate. The eligibility of each client for the Project Wings, Persons With Disabilities, and Other Transportation programs is not based upon race, color, creed, religious beliefs, sexual orientation or age, but is based upon need.
The Senior Transportation Program is made possible by funding from the New York State Office for the Aging, Title III of the Older Americans Act, and the Counties of Jefferson and Lewis. This program is for persons 60 years of age or older. This program does not discriminate.
DO NOT PUT ANY APPOINTMENT INFORMATION ON THIS FORM. You will be notified by the Volunteer Transportation Center of your approval status.
RELEASE FORM MUST BE COMPLETED BEFORE TRANSPORTATION CAN BE APPROVED
I give permission for the client listed above to be transported by the volunteer drivers from the Volunteer Transportation Center, Inc. The client will not hold any volunteer driver nor the Volunteer Transportation Center’s staff and/or Board of Directors responsible for any injury to the above named client that occurs during the course of transportation, destination, and return home. This also includes returning the client home while noting that no other individual is at the home destination to oversee this client.
You may use your finger or mouse to complete the signature block.