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RSVP Transportation Client Application

Your Information

Sex
Male
Female
How often do you anticipate requesting rides provided by RSVP volunteers?
1-2 times/week
1-2 times/month
Less than 6 times/year
Other
Do you currently drive, or drive with restrictions?
No
Yes
If you do drive, what best describes your current situation?
I am temporarily unable to drive due to a medical situation
I am unable to drive in particular locations (i.e. large cities or outside the town I live in)
I am unable to drive due to vehicle issues/access
I am unable to drive because I lost my license
Other
What transportation services are you currently accessing? (check all that apply)
Are you eligible for Medicaid transportation assistance?
Yes
No
Have you ever been convicted of a crime?
Yes
No
Is there any law enforcement agency, parole, or probation officer you are required to report to?
Yes
No

Emergency Contact

Consents & Signature

I agree to comply with all terms, including approval for an assessment. I understand that the information provided on this registration form is confidential and will NOT be shared or used by RSVP except for the purpose of providing transportation services. I hereby agree to indemnify and hold harmless Central Iowa RSVP and its participants against any and all liability, loss, damage, costs, or expenses which I may sustain, incur, or be required to pay because of injury, death, property loss, or damage while being transported.

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