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RSVP Transportation Client Application

Your Information

Gender
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?
Yes
No
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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