Application For Services – Senior Rides And More

Name *

First

Last

Gender *

Male
Female

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Complex Name & Gate Code

Home Phone

Cell Phone *

Primary Language *

Date Of Birth *

Emergency Contact

First

Last

Relationship *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Former Occupation(s)

Other Living In The Household *

Physical Assistance Required *

Yes
No

Religious Affiliation

Are You A Veteran *

Yes
No

Have You Had A Covid Vaccine *

Services Requested *

Transportation
Shopping
Receive Friendly Phone Calls

Other Services Requested

Print Name *

Date *

Signature *

Clear Signature

CARERECEIVER AGREEMENT *

I understand that this is a volunteer organization and that while all reasonable attempts will be made to meet my request, services cannot be guaranteed. We are NOT an emergency organization.
I agree to communicate all of my needs through the Senior Rides office a minimum of four (4) full weekdays days prior to my appointment. However, one full week’s notice would be greatly appreciated.
I agree to provide the Senior Rides office and my volunteer detailed directions to my home, destination and to inform them in advance when I will be using a walker. Care Receivers must be able to walk unassisted. Please remember that we are unable to accommodate wheelchairs.
I understand that Senior Rides volunteers cannot sign official documents or take medication or care orders from my physicians or other medical personnel.
I agree to provide my physicians names, addresses, phone numbers, two emergency contacts and other applicable information as requested by the Senior Rides Application.
I agree to adhere to the stated times and services. I will not request additional services from a volunteer or request their phone number.
I understand that all services are for registered Senior Rides care receivers only. I will not request transportation or any other assistance for someone who is not registered with Senior Rides as a care receiver.
I understand that all services associated with Senior Rides are complimentary and no payment is requested or expected for these services.

Print Name *

Date *

Signature *

Clear Signature

CR PARTICIPATION AGREEMENT AND WAIVER OF LIABILITY *

I understand that Senior Rides and More services are provided by volunteers, and transportation is provided in their vehicles. I have re a copy of Senior Rides and More’s Care Receiver brochure and I understand and agree to abide by its guidelines.
If I am involved in an incident involving known or suspected injury or damage to persons or property, I will make a written report to Senior Rides.
I understand that Senior Rides assumes no responsibility or liability for any loss, damage, or injury to persons or property as a result of receiving the services of Senior Rides, and that my participation in Senior Rides indicates my awareness and acceptance of the preceding disclaimer of responsibility and liability. I agree to release Senior Rides and all of its officers, board members, staff, volunteers, and clients, without limitation or qualification, from any and all liabilities, and claims, which might be made for any losses, expenses, acts of nature, or damages of any kind or description. I understand that it is my responsibility to secure my own appropriate medical, automobile, and/or personal injury insurance coverage for my own protection.

Print Name *

Date *

Signature *

Clear Signature