{"id":1391,"date":"2022-09-09T22:12:25","date_gmt":"2022-09-09T22:12:25","guid":{"rendered":"https:\/\/seniorridesandmore.org\/?page_id=1391"},"modified":"2022-09-12T20:06:34","modified_gmt":"2022-09-12T20:06:34","slug":"application-for-services","status":"publish","type":"page","link":"https:\/\/seniorridesandmore.org\/?page_id=1391","title":{"rendered":"Application For Services"},"content":{"rendered":"\n<div class=\"wp-block-cover alignfull is-light\" style=\"min-height:700px;aspect-ratio:unset;\"><span aria-hidden=\"true\" class=\"wp-block-cover__background has-ast-global-color-1-background-color has-background-dim-0 has-background-dim\"><\/span><img loading=\"lazy\" decoding=\"async\" width=\"2560\" height=\"1707\" class=\"wp-block-cover__image-background wp-image-29\" alt=\"\" src=\"http:\/\/seniorridesandmore.org\/wp-content\/uploads\/2022\/08\/Elderly_Hands-scaled.jpg\" style=\"object-position:52% 39%\" data-object-fit=\"cover\" data-object-position=\"52% 39%\" srcset=\"https:\/\/seniorridesandmore.org\/wp-content\/uploads\/2022\/08\/Elderly_Hands-scaled.jpg 2560w, https:\/\/seniorridesandmore.org\/wp-content\/uploads\/2022\/08\/Elderly_Hands-300x200.jpg 300w, https:\/\/seniorridesandmore.org\/wp-content\/uploads\/2022\/08\/Elderly_Hands-1024x683.jpg 1024w, https:\/\/seniorridesandmore.org\/wp-content\/uploads\/2022\/08\/Elderly_Hands-768x512.jpg 768w, https:\/\/seniorridesandmore.org\/wp-content\/uploads\/2022\/08\/Elderly_Hands-1536x1024.jpg 1536w, https:\/\/seniorridesandmore.org\/wp-content\/uploads\/2022\/08\/Elderly_Hands-2048x1365.jpg 2048w\" sizes=\"auto, (max-width: 2560px) 100vw, 2560px\" \/><div class=\"wp-block-cover__inner-container is-layout-flow wp-block-cover-is-layout-flow\">\n<p class=\"has-text-align-center has-large-font-size wp-block-paragraph\"><\/p>\n<\/div><\/div>\n\n\n\n<div class=\"wp-block-cover alignfull\" style=\"min-height:400px;aspect-ratio:unset;\"><span aria-hidden=\"true\" class=\"wp-block-cover__background has-background-dim-100 has-background-dim\" style=\"background-color:#00394e\"><\/span><div class=\"wp-block-cover__inner-container is-layout-flow wp-block-cover-is-layout-flow\">\n<div style=\"height:75px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n\n<div class=\"wp-block-cover alignwide is-light\"><span aria-hidden=\"true\" class=\"wp-block-cover__background has-white-background-color has-background-dim-100 has-background-dim\"><\/span><div class=\"wp-block-cover__inner-container is-layout-flow wp-block-cover-is-layout-flow\">\n<div style=\"height:75px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n\n<div class=\"wp-block-group is-vertical is-content-justification-center is-layout-flex wp-container-core-group-is-layout-524f8de7 wp-block-group-is-layout-flex\">\n<h1 class=\"has-text-align-center has-black-color has-text-color wp-block-heading\" style=\"font-size:28px;font-style:normal;font-weight:600;letter-spacing:0.5px\">Application For Services<\/h1>\n\n\n\n<div style=\"height:25px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n<div class=\"wpforms-container wpforms-container-full\" id=\"wpforms-863\"><form id=\"wpforms-form-863\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"863\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F1391\" data-token=\"9c0b6eea59ca6aa84c2143a4b1d3ce42\" data-token-time=\"1782941869\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-field-container\"><div id=\"wpforms-863-field_3-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-863-field_3\">Name <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-small\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-863-field_3\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][3][first]\" placeholder=\"First Name Here\" required><label for=\"wpforms-863-field_3\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-863-field_3-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][3][last]\" placeholder=\"Last Name Here\" required><label for=\"wpforms-863-field_3-last\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Last<\/label><\/div><\/div><\/div><div id=\"wpforms-863-field_2-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"2\"><label class=\"wpforms-field-label\">Gender <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-863-field_2\" class=\"wpforms-field-required\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-863-field_2_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][2][]\" value=\"Male\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-863-field_2_1\">Male<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-863-field_2_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][2][]\" value=\"Female\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-863-field_2_2\">Female<\/label><\/li><\/ul><\/div><div id=\"wpforms-863-field_32-container\" class=\"wpforms-field wpforms-field-address\" data-field-id=\"32\"><label class=\"wpforms-field-label\">Address <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-863-field_32\" class=\"wpforms-field-address-address1 wpforms-field-required\" name=\"wpforms[fields][32][address1]\" required><label for=\"wpforms-863-field_32\" class=\"wpforms-field-sublabel after\">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-863-field_32-address2\" class=\"wpforms-field-address-address2\" name=\"wpforms[fields][32][address2]\" ><label for=\"wpforms-863-field_32-address2\" class=\"wpforms-field-sublabel after\">Address Line 2<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-863-field_32-city\" class=\"wpforms-field-address-city wpforms-field-required\" name=\"wpforms[fields][32][city]\" required><label for=\"wpforms-863-field_32-city\" class=\"wpforms-field-sublabel after\">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-863-field_32-state\" class=\"wpforms-field-address-state wpforms-field-required\" name=\"wpforms[fields][32][state]\" required><option class=\"placeholder\" value=\"\" selected disabled>--- Select state ---<\/option><option value=\"AL\" >Alabama<\/option><option value=\"AK\" >Alaska<\/option><option value=\"AZ\" >Arizona<\/option><option value=\"AR\" >Arkansas<\/option><option value=\"CA\" >California<\/option><option value=\"CO\" >Colorado<\/option><option value=\"CT\" >Connecticut<\/option><option value=\"DE\" >Delaware<\/option><option value=\"DC\" >District of Columbia<\/option><option value=\"FL\" >Florida<\/option><option value=\"GA\" >Georgia<\/option><option value=\"HI\" >Hawaii<\/option><option value=\"ID\" >Idaho<\/option><option value=\"IL\" >Illinois<\/option><option value=\"IN\" >Indiana<\/option><option value=\"IA\" >Iowa<\/option><option value=\"KS\" >Kansas<\/option><option value=\"KY\" >Kentucky<\/option><option value=\"LA\" >Louisiana<\/option><option value=\"ME\" >Maine<\/option><option value=\"MD\" >Maryland<\/option><option value=\"MA\" >Massachusetts<\/option><option value=\"MI\" >Michigan<\/option><option value=\"MN\" >Minnesota<\/option><option value=\"MS\" >Mississippi<\/option><option value=\"MO\" >Missouri<\/option><option value=\"MT\" >Montana<\/option><option value=\"NE\" >Nebraska<\/option><option value=\"NV\" >Nevada<\/option><option value=\"NH\" >New Hampshire<\/option><option value=\"NJ\" >New Jersey<\/option><option value=\"NM\" >New Mexico<\/option><option value=\"NY\" >New York<\/option><option value=\"NC\" >North Carolina<\/option><option value=\"ND\" >North Dakota<\/option><option value=\"OH\" >Ohio<\/option><option value=\"OK\" >Oklahoma<\/option><option value=\"OR\" >Oregon<\/option><option value=\"PA\" >Pennsylvania<\/option><option value=\"RI\" >Rhode Island<\/option><option value=\"SC\" >South Carolina<\/option><option value=\"SD\" >South Dakota<\/option><option value=\"TN\" >Tennessee<\/option><option value=\"TX\" >Texas<\/option><option value=\"UT\" >Utah<\/option><option value=\"VT\" >Vermont<\/option><option value=\"VA\" >Virginia<\/option><option value=\"WA\" >Washington<\/option><option value=\"WV\" >West Virginia<\/option><option value=\"WI\" >Wisconsin<\/option><option value=\"WY\" >Wyoming<\/option><\/select><label for=\"wpforms-863-field_32-state\" class=\"wpforms-field-sublabel after\">State<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-863-field_32-postal\" class=\"wpforms-field-address-postal wpforms-field-required wpforms-masked-input\" data-inputmask-mask=\"(99999)|(99999-9999)\" data-inputmask-keepstatic=\"true\" data-rule-inputmask-incomplete=\"1\" name=\"wpforms[fields][32][postal]\" required><label for=\"wpforms-863-field_32-postal\" class=\"wpforms-field-sublabel after\">Zip Code<\/label><\/div><\/div><\/div><div id=\"wpforms-863-field_7-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"7\"><label class=\"wpforms-field-label\" for=\"wpforms-863-field_7\">Complex Name &amp; Gate Code<\/label><input type=\"text\" id=\"wpforms-863-field_7\" class=\"wpforms-field-small\" name=\"wpforms[fields][7]\" placeholder=\"Apartment Complex Name And Gate Code Here - If Applicable\" ><\/div><div id=\"wpforms-863-field_33-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"33\"><label class=\"wpforms-field-label\" for=\"wpforms-863-field_33\">Home Phone<\/label><input type=\"tel\" id=\"wpforms-863-field_33\" class=\"wpforms-field-small wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][33]\" aria-label=\"Home Phone\" ><\/div><div id=\"wpforms-863-field_34-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"34\"><label class=\"wpforms-field-label\" for=\"wpforms-863-field_34\">Cell Phone <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-863-field_34\" class=\"wpforms-field-small wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][34]\" aria-label=\"Cell Phone\" required><\/div><div id=\"wpforms-863-field_11-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-863-field_11\">Primary Language <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-863-field_11\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][11]\" placeholder=\"Language Here\" required><\/div><div id=\"wpforms-863-field_12-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-863-field_12\">Date Of Birth <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-863-field_12\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][12]\" placeholder=\"Birth Date Here\" required><\/div><div id=\"wpforms-863-field_13-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"13\"><label class=\"wpforms-field-label\" for=\"wpforms-863-field_13\">Emergency Contact<\/label><div class=\"wpforms-field-row wpforms-field-small\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-863-field_13\" class=\"wpforms-field-name-first\" name=\"wpforms[fields][13][first]\" placeholder=\"First Name Here\" ><label for=\"wpforms-863-field_13\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-863-field_13-last\" class=\"wpforms-field-name-last\" name=\"wpforms[fields][13][last]\" placeholder=\"Last Name Here\" ><label for=\"wpforms-863-field_13-last\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Last<\/label><\/div><\/div><\/div><div id=\"wpforms-863-field_35-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"35\"><label class=\"wpforms-field-label\" for=\"wpforms-863-field_35\">Relationship <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-863-field_35\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][35]\" required><\/div><div id=\"wpforms-863-field_36-container\" class=\"wpforms-field wpforms-field-address\" data-field-id=\"36\"><label class=\"wpforms-field-label\">Address<\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-863-field_36\" class=\"wpforms-field-address-address1\" name=\"wpforms[fields][36][address1]\" ><label for=\"wpforms-863-field_36\" class=\"wpforms-field-sublabel after\">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-863-field_36-address2\" class=\"wpforms-field-address-address2\" name=\"wpforms[fields][36][address2]\" ><label for=\"wpforms-863-field_36-address2\" class=\"wpforms-field-sublabel after\">Address Line 2<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-863-field_36-city\" class=\"wpforms-field-address-city\" name=\"wpforms[fields][36][city]\" ><label for=\"wpforms-863-field_36-city\" class=\"wpforms-field-sublabel after\">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-863-field_36-state\" class=\"wpforms-field-address-state\" name=\"wpforms[fields][36][state]\" ><option class=\"placeholder\" value=\"\" selected disabled>--- Select state ---<\/option><option value=\"AL\" >Alabama<\/option><option value=\"AK\" >Alaska<\/option><option value=\"AZ\" >Arizona<\/option><option value=\"AR\" >Arkansas<\/option><option value=\"CA\" >California<\/option><option value=\"CO\" >Colorado<\/option><option value=\"CT\" >Connecticut<\/option><option value=\"DE\" >Delaware<\/option><option value=\"DC\" >District of Columbia<\/option><option value=\"FL\" >Florida<\/option><option value=\"GA\" >Georgia<\/option><option value=\"HI\" >Hawaii<\/option><option value=\"ID\" >Idaho<\/option><option value=\"IL\" >Illinois<\/option><option value=\"IN\" >Indiana<\/option><option value=\"IA\" >Iowa<\/option><option value=\"KS\" >Kansas<\/option><option value=\"KY\" >Kentucky<\/option><option value=\"LA\" >Louisiana<\/option><option value=\"ME\" >Maine<\/option><option value=\"MD\" >Maryland<\/option><option value=\"MA\" >Massachusetts<\/option><option value=\"MI\" >Michigan<\/option><option value=\"MN\" >Minnesota<\/option><option value=\"MS\" >Mississippi<\/option><option value=\"MO\" >Missouri<\/option><option value=\"MT\" >Montana<\/option><option value=\"NE\" >Nebraska<\/option><option value=\"NV\" >Nevada<\/option><option value=\"NH\" >New Hampshire<\/option><option value=\"NJ\" >New Jersey<\/option><option value=\"NM\" >New Mexico<\/option><option value=\"NY\" >New York<\/option><option value=\"NC\" >North Carolina<\/option><option value=\"ND\" >North Dakota<\/option><option value=\"OH\" >Ohio<\/option><option value=\"OK\" >Oklahoma<\/option><option value=\"OR\" >Oregon<\/option><option value=\"PA\" >Pennsylvania<\/option><option value=\"RI\" >Rhode Island<\/option><option value=\"SC\" >South Carolina<\/option><option value=\"SD\" >South Dakota<\/option><option value=\"TN\" >Tennessee<\/option><option value=\"TX\" >Texas<\/option><option value=\"UT\" >Utah<\/option><option value=\"VT\" >Vermont<\/option><option value=\"VA\" >Virginia<\/option><option value=\"WA\" >Washington<\/option><option value=\"WV\" >West Virginia<\/option><option value=\"WI\" >Wisconsin<\/option><option value=\"WY\" >Wyoming<\/option><\/select><label for=\"wpforms-863-field_36-state\" class=\"wpforms-field-sublabel after\">State<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-863-field_36-postal\" class=\"wpforms-field-address-postal wpforms-masked-input\" data-inputmask-mask=\"(99999)|(99999-9999)\" data-inputmask-keepstatic=\"true\" data-rule-inputmask-incomplete=\"1\" name=\"wpforms[fields][36][postal]\" ><label for=\"wpforms-863-field_36-postal\" class=\"wpforms-field-sublabel after\">Zip Code<\/label><\/div><\/div><\/div><div id=\"wpforms-863-field_37-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"37\"><label class=\"wpforms-field-label\" for=\"wpforms-863-field_37\">Phone <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-863-field_37\" class=\"wpforms-field-small wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][37]\" aria-label=\"Phone\" required><\/div><div id=\"wpforms-863-field_19-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"19\"><label class=\"wpforms-field-label\" for=\"wpforms-863-field_19\">Former Occupation(s)<\/label><input type=\"text\" id=\"wpforms-863-field_19\" class=\"wpforms-field-small\" name=\"wpforms[fields][19]\" placeholder=\"Occupations Here\" ><\/div><div id=\"wpforms-863-field_20-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"20\"><label class=\"wpforms-field-label\" for=\"wpforms-863-field_20\">Other Living In The Household <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-863-field_20\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][20]\" placeholder=\"Names Here\" required><\/div><div id=\"wpforms-863-field_38-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"38\"><label class=\"wpforms-field-label\">Physical Assistance Required <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-863-field_38\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-863-field_38_1\" name=\"wpforms[fields][38]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-863-field_38_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-863-field_38_2\" name=\"wpforms[fields][38]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-863-field_38_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-863-field_22-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"22\"><label class=\"wpforms-field-label\" for=\"wpforms-863-field_22\">Religious Affiliation<\/label><input type=\"text\" id=\"wpforms-863-field_22\" class=\"wpforms-field-medium\" name=\"wpforms[fields][22]\" placeholder=\"Affliation or Membership Here\" ><\/div><div id=\"wpforms-863-field_39-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"39\"><label class=\"wpforms-field-label\">Are You A Veteran <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-863-field_39\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-863-field_39_1\" name=\"wpforms[fields][39]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-863-field_39_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-863-field_39_2\" name=\"wpforms[fields][39]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-863-field_39_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-863-field_26-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"26\"><label class=\"wpforms-field-label\">Have You Had A Covid Vaccine <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-863-field_26\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-863-field_26_1\" name=\"wpforms[fields][26][]\" value=\"First Vaccine\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-863-field_26_1\">First Vaccine<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-863-field_26_2\" name=\"wpforms[fields][26][]\" value=\"Second Vaccine\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-863-field_26_2\">Second Vaccine<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-863-field_26_3\" name=\"wpforms[fields][26][]\" value=\"First Booster\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-863-field_26_3\">First Booster<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-863-field_26_4\" name=\"wpforms[fields][26][]\" value=\"Fully Vaccinated\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-863-field_26_4\">Fully Vaccinated<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-863-field_26_5\" name=\"wpforms[fields][26][]\" value=\"Not Vaccinated\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-863-field_26_5\">Not Vaccinated<\/label><\/li><\/ul><\/div><div id=\"wpforms-863-field_41-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"41\"><label class=\"wpforms-field-label\">Services Requested <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-863-field_41\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-863-field_41_1\" name=\"wpforms[fields][41][]\" value=\"Transportation\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-863-field_41_1\">Transportation<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-863-field_41_2\" name=\"wpforms[fields][41][]\" value=\"Shopping\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-863-field_41_2\">Shopping<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-863-field_41_3\" name=\"wpforms[fields][41][]\" value=\"Receive Friendly Phone Calls\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-863-field_41_3\">Receive Friendly Phone Calls<\/label><\/li><\/ul><\/div><div id=\"wpforms-863-field_24-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"24\"><label class=\"wpforms-field-label\" for=\"wpforms-863-field_24\">Other Services Requested<\/label><input type=\"text\" id=\"wpforms-863-field_24\" class=\"wpforms-field-medium\" name=\"wpforms[fields][24]\" placeholder=\"Other Services You Would Like To Receive Here\" ><\/div><div id=\"wpforms-863-field_50-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"50\"><label class=\"wpforms-field-label\" for=\"wpforms-863-field_50\">Print Name <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-863-field_50\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][50]\" required><\/div><div id=\"wpforms-863-field_43-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"43\"><label class=\"wpforms-field-label\" for=\"wpforms-863-field_43\">Date <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-863-field_43\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-small\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][43][date]\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-863-field_42-container\" class=\"wpforms-field wpforms-field-signature\" data-field-id=\"42\"><label class=\"wpforms-field-label\" for=\"wpforms-863-field_42\">Signature <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-863-field_42\" class=\"wpforms-signature-input wpforms-screen-reader-element wpforms-field-required\" data-is-wrapped-field=\"1\" name=\"wpforms[fields][42]\" autocomplete=\"off\" inputmode=\"none\" required><div class=\"wpforms-signature-wrap wpforms-field-row wpforms-field-medium\"><canvas class=\"wpforms-signature-canvas\" id=\"wpforms-863-field_42-signature\" data-color=\"#000000\"><\/canvas><div class=\"wpforms-signature-clear\" title=\"Clear Signature\" tabindex=\"0\">\n\t\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"1em\" height=\"1em\" preserveAspectRatio=\"xMidYMid meet\" viewBox=\"0 0 1536 1536\">\n\t\t\t\t\t<path fill=\"var( --wpforms-field-text-color, rgba(0, 0, 0, 0.25) )\" d=\"M1149 994q0-26-19-45L949 768l181-181q19-19 19-45q0-27-19-46l-90-90q-19-19-46-19q-26 0-45 19L768 587L587 406q-19-19-45-19q-27 0-46 19l-90 90q-19 19-19 46q0 26 19 45l181 181l-181 181q-19 19-19 45q0 27 19 46l90 90q19 19 46 19q26 0 45-19l181-181l181 181q19 19 45 19q27 0 46-19l90-90q19-19 19-46zm387-226q0 209-103 385.5T1153.5 1433T768 1536t-385.5-103T103 1153.5T0 768t103-385.5T382.5 103T768 0t385.5 103T1433 382.5T1536 768z\"\/>\n\t\t\t\t<\/svg>\n\t\t\t\t<div class=\"wpforms-signature-clear-caption\">Clear Signature<\/div>\n\t\t\t<\/div><\/div><\/div><div id=\"wpforms-863-field_30-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"30\"><label class=\"wpforms-field-label\">CARERECEIVER AGREEMENT <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-863-field_30\" class=\"wpforms-field-required\" data-choice-limit=\"8\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-863-field_30_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][30][]\" value=\"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.\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-863-field_30_1\">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.<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-863-field_30_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][30][]\" value=\"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\u2019s notice would be greatly appreciated.\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-863-field_30_2\">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\u2019s notice would be greatly appreciated.<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-863-field_30_3\" data-rule-check-limit=\"true\" name=\"wpforms[fields][30][]\" value=\"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.\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-863-field_30_3\">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.<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-863-field_30_4\" data-rule-check-limit=\"true\" name=\"wpforms[fields][30][]\" value=\"I understand that Senior Rides volunteers cannot sign official documents or take medication or care orders from my physicians or other medical personnel. \" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-863-field_30_4\">I understand that Senior Rides volunteers cannot sign official documents or take medication or care orders from my physicians or other medical personnel.<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-863-field_30_5\" data-rule-check-limit=\"true\" name=\"wpforms[fields][30][]\" value=\"I agree to provide my physicians names, addresses, phone numbers, two emergency contacts and other applicable information as requested by the Senior Rides Application.\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-863-field_30_5\">I agree to provide my physicians names, addresses, phone numbers, two emergency contacts and other applicable information as requested by the Senior Rides Application.<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-863-field_30_6\" data-rule-check-limit=\"true\" name=\"wpforms[fields][30][]\" value=\"I agree to adhere to the stated times and services. I will not request additional services from a volunteer or request their phone number.\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-863-field_30_6\">I agree to adhere to the stated times and services. I will not request additional services from a volunteer or request their phone number.<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-863-field_30_7\" data-rule-check-limit=\"true\" name=\"wpforms[fields][30][]\" value=\"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.\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-863-field_30_7\">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.<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-863-field_30_8\" data-rule-check-limit=\"true\" name=\"wpforms[fields][30][]\" value=\"I understand that all services associated with Senior Rides are complimentary and no payment is requested or expected for these services.\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-863-field_30_8\">I understand that all services associated with Senior Rides are complimentary and no payment is requested or expected for these services.<\/label><\/li><\/ul><\/div><div id=\"wpforms-863-field_46-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"46\"><label class=\"wpforms-field-label\" for=\"wpforms-863-field_46\">Print Name <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-863-field_46\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][46]\" required><\/div><div id=\"wpforms-863-field_45-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"45\"><label class=\"wpforms-field-label\" for=\"wpforms-863-field_45\">Date <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-863-field_45\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-small\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][45][date]\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-863-field_44-container\" class=\"wpforms-field wpforms-field-signature\" data-field-id=\"44\"><label class=\"wpforms-field-label\" for=\"wpforms-863-field_44\">Signature <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-863-field_44\" class=\"wpforms-signature-input wpforms-screen-reader-element wpforms-field-required\" data-is-wrapped-field=\"1\" name=\"wpforms[fields][44]\" autocomplete=\"off\" inputmode=\"none\" required><div class=\"wpforms-signature-wrap wpforms-field-row wpforms-field-medium\"><canvas class=\"wpforms-signature-canvas\" id=\"wpforms-863-field_44-signature\" data-color=\"#000000\"><\/canvas><div class=\"wpforms-signature-clear\" title=\"Clear Signature\" tabindex=\"0\">\n\t\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"1em\" height=\"1em\" preserveAspectRatio=\"xMidYMid meet\" viewBox=\"0 0 1536 1536\">\n\t\t\t\t\t<path fill=\"var( --wpforms-field-text-color, rgba(0, 0, 0, 0.25) )\" d=\"M1149 994q0-26-19-45L949 768l181-181q19-19 19-45q0-27-19-46l-90-90q-19-19-46-19q-26 0-45 19L768 587L587 406q-19-19-45-19q-27 0-46 19l-90 90q-19 19-19 46q0 26 19 45l181 181l-181 181q-19 19-19 45q0 27 19 46l90 90q19 19 46 19q26 0 45-19l181-181l181 181q19 19 45 19q27 0 46-19l90-90q19-19 19-46zm387-226q0 209-103 385.5T1153.5 1433T768 1536t-385.5-103T103 1153.5T0 768t103-385.5T382.5 103T768 0t385.5 103T1433 382.5T1536 768z\"\/>\n\t\t\t\t<\/svg>\n\t\t\t\t<div class=\"wpforms-signature-clear-caption\">Clear Signature<\/div>\n\t\t\t<\/div><\/div><\/div><div id=\"wpforms-863-field_31-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"31\"><label class=\"wpforms-field-label\">CR PARTICIPATION AGREEMENT AND WAIVER OF LIABILITY <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-863-field_31\" class=\"wpforms-field-required\" data-choice-limit=\"3\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-863-field_31_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][31][]\" value=\"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\u2019s Care Receiver brochure and I understand and agree to abide by its guidelines.\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-863-field_31_1\">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\u2019s Care Receiver brochure and I understand and agree to abide by its guidelines.<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-863-field_31_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][31][]\" value=\"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.\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-863-field_31_2\">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.<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-863-field_31_3\" data-rule-check-limit=\"true\" name=\"wpforms[fields][31][]\" value=\"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.\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-863-field_31_3\">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.<\/label><\/li><\/ul><\/div><div id=\"wpforms-863-field_49-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"49\"><label class=\"wpforms-field-label\" for=\"wpforms-863-field_49\">Print Name <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-863-field_49\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][49]\" required><\/div><div id=\"wpforms-863-field_48-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"48\"><label class=\"wpforms-field-label\" for=\"wpforms-863-field_48\">Date <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-863-field_48\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-small\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][48][date]\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-863-field_47-container\" class=\"wpforms-field wpforms-field-signature\" data-field-id=\"47\"><label class=\"wpforms-field-label\" for=\"wpforms-863-field_47\">Signature <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-863-field_47\" class=\"wpforms-signature-input wpforms-screen-reader-element wpforms-field-required\" data-is-wrapped-field=\"1\" name=\"wpforms[fields][47]\" autocomplete=\"off\" inputmode=\"none\" required><div class=\"wpforms-signature-wrap wpforms-field-row wpforms-field-medium\"><canvas class=\"wpforms-signature-canvas\" id=\"wpforms-863-field_47-signature\" data-color=\"#000000\"><\/canvas><div class=\"wpforms-signature-clear\" title=\"Clear Signature\" tabindex=\"0\">\n\t\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"1em\" height=\"1em\" preserveAspectRatio=\"xMidYMid meet\" viewBox=\"0 0 1536 1536\">\n\t\t\t\t\t<path fill=\"var( --wpforms-field-text-color, rgba(0, 0, 0, 0.25) )\" d=\"M1149 994q0-26-19-45L949 768l181-181q19-19 19-45q0-27-19-46l-90-90q-19-19-46-19q-26 0-45 19L768 587L587 406q-19-19-45-19q-27 0-46 19l-90 90q-19 19-19 46q0 26 19 45l181 181l-181 181q-19 19-19 45q0 27 19 46l90 90q19 19 46 19q26 0 45-19l181-181l181 181q19 19 45 19q27 0 46-19l90-90q19-19 19-46zm387-226q0 209-103 385.5T1153.5 1433T768 1536t-385.5-103T103 1153.5T0 768t103-385.5T382.5 103T768 0t385.5 103T1433 382.5T1536 768z\"\/>\n\t\t\t\t<\/svg>\n\t\t\t\t<div class=\"wpforms-signature-clear-caption\">Clear Signature<\/div>\n\t\t\t<\/div><\/div><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-recaptcha-container wpforms-is-recaptcha wpforms-is-recaptcha-type-v3\" ><input type=\"hidden\" name=\"wpforms[recaptcha]\" value=\"\"><\/div><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"863\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/seniorridesandmore.org\/index.php?rest_route=\/wp\/v2\/pages\/1391\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-863\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/seniorridesandmore.org\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container -->\n<\/div>\n\n\n\n<div style=\"height:75px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n<\/div><\/div>\n\n\n\n<div style=\"height:75px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n<\/div><\/div>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-1391","page","type-page","status-publish","hentry","entry"],"_links":{"self":[{"href":"https:\/\/seniorridesandmore.org\/index.php?rest_route=\/wp\/v2\/pages\/1391","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/seniorridesandmore.org\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/seniorridesandmore.org\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/seniorridesandmore.org\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/seniorridesandmore.org\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=1391"}],"version-history":[{"count":3,"href":"https:\/\/seniorridesandmore.org\/index.php?rest_route=\/wp\/v2\/pages\/1391\/revisions"}],"predecessor-version":[{"id":1420,"href":"https:\/\/seniorridesandmore.org\/index.php?rest_route=\/wp\/v2\/pages\/1391\/revisions\/1420"}],"wp:attachment":[{"href":"https:\/\/seniorridesandmore.org\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=1391"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}