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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 *
Phone Number *
Address *
Do You Have a Vehicle?
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Do you use any mobility devices or aids? (Wheelchair, cane, walker, etc.)
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If you answered "Yes" or "Other" to the above question, please explain.
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