Required fields are marked with asterisks (*)

MyLift Transportation Registration Form

Please complete this form in full if you are looking to register for rides on the MyLift Bus. The form will be sent to the MyLift Coordinator and you will then be able to call for rides.

First Name:

Last Name:

Address:

Home Phone:

Cell Phone:

Date of Birth (mm/dd/yyyy):

Emergency Contact Name:

Relationship to Emerg. Contact:

Emerg. Contact Phone Number:

Rider Eligibility (select all that apply):

Senior (age 55+)

Low Income

Disabled

Temporary Disabled (Post-surgery, Physio, etc.)

Patricia Senior Services Client

Other Agency referral

What type of disability are you living with? Select all that apply.

Temp or Rehab

Hearing

Oxygen

Vision

Developmental

Mobility

None

What type of mobility aid do you use? Select all that apply.

Cane

Crutches

Manual Wheelchair

Walker

Prosthesis

E/W/C

None

Do you require an attendant?

Yes

Do you require a service animal?

Yes

Agreement

I understand that the purpose of this application form is to assist in determining whether I am eligible to be a registered Client for MyLift. It is also to determine what type of services I require and what we can provide. I understand that the information in this form will be shared with designated employees of the City of Dryden Community Services department, for the purpose of processing this application.

I understand that all information will be kept CONFIDENTIAL between the City of Dryden and the parties specified above.

I hereby certify that to the best of my knowledge, the information provided on this application is correct.

Signature of Applicant:

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MyLift Transportation Registration Form

Agreement

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