Name
*
First Name
Last Name
Date of birth
*
MM
DD
YYYY
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email Address
*
Phone
*
(###)
###
####
Emergency Contact
*
First Name
Last Name
Emergency Contact phone number
*
(###)
###
####
Are you 60 years of age or older?
*
Yes
No
Do you have a driver’s license?
Yes
No
Do you currently drive?
*
Yes
No (temporarily)
No (Permanently)
Please specify (optional)
Do you have a specific disability that makes you unable to drive?
*
Yes
No
If yes, please specify:
In the last several years, have you cut down on your long-distance driving?
Yes
No
In the last several years, have you cut down on night driving?
Yes
No
Are you enrolled in any other transportation program(s)?
*
Yes
No
If yes, which one(s)?
Do you require someone to travel with you?
*
Yes
No
Do you use oxygen?
*
Yes
No
Do you use a wheelchair?
*
Yes
No
If yes, can you transfer?
Do you use a walker/rollator?
*
Yes
No
If yes, which one?
Do you have any extenuating financial circumstances that prevent you from paying for the voucher book? ($80.00/book)
*
Yes
No
N/A (I am only applying for the free volunteer transportation)
If yes, please specify briefly and a JFS social worker will contact you
Are you a member of a synagogue?
*
Yes
No
If yes, which one?
Please list your anticipated transportation needs and frequency (e.g religious services, medical appointments, grocery shopping, etc.)
*
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