Easy Ride Client Information
New Client Intake
Legal Name (Last, First) *
Your answer
Client Email Address
Your answer
Primary Phone Number *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Gender *
Do you live alone? *
If you are under the age of 60, do you have a disability as defined under the Americans with Disabilities Act (ADA)? If yes, you must provide us with a statement, on letterhead, from a medical provider verifying that you have a disability as defined under the ADA.
If you live alone, is your monthly income below $1,041 per month? (Services are not based on income).
If you have a spouse or partner, is your monthly household income below $1,409 per month? (Services are not based on income).
Residential Address (include Apt/Unit #) *
Your answer
City, Zip *
Your answer
Mobility *
Required
Wheelchair (if used)
Transfers from chair to bus seat?
Will the rider have an escort?
Unstable, needs assistance? *
Are you able to walk up and down four stairs? *
Transported with oxygen? *
Medical Conditions (choose all that apply)
What is your race?
Are you a Veteran?
Emergency Contact Name *
Your answer
Emergency Contact Phone Number *
Your answer
Emergency Contact Relationship to Client?
Your answer
Secondary Emergency Contact
Your answer
Secondary Emergency Contact Phone Number
Your answer
Secondary Emergency Contact Relationship to Client?
Your answer
Please type name below as signature *
Your answer
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