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Wellness Wagon Rider Application
Hi! This is an application form for VINES' Wellness Wagon program! This form will be reviewed shortly after completion and you will be notified of your application status soon after!
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First Name *
Last Name *
Date of Birth *
MM
/
DD
/
YYYY
Phone Number *
Address *
Email
Do You Have a Vehicle?
Clear selection
Do you use any mobility devices or aids? (Wheelchair, cane, walker, etc.)
Clear selection
If you answered "Yes" or "Other" to the above question, please explain.
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