Easy Ride Client Information
New Client Intake
If you are under 60 you must have an ADA qualifying disability. Please call 303.464.5534 for assistance.
Welcome! Please tell us a bit about yourself so we can offer services that best meet your needs. We ask for demographic information to meet requirements from our funders. All your personal information is confidential.
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Legal Name (Last, First) *
Client Email Address
Primary Phone Number *
Date of Birth *
MM
/
DD
/
YYYY
Gender *
Do you live alone? *
If you live alone, is your monthly income below $1,215 per month? (Services are not based on income).
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Residential Address (include Apt/Unit #) *
City, Zip *
Mobility *
Required
Wheelchair (if used)
Transfers from chair to bus seat?
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Will the rider have an escort?
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Unstable, needs assistance? *
Are you able to walk up and down four stairs? *
Transported with oxygen? *
Medical Conditions (choose all that apply)
Race:
Ethnicity:
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Primary Language:
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Are you a Veteran?
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Emergency Contact Name *
Emergency Contact Phone Number *
Emergency Contact Relationship to Client?
Secondary Emergency Contact
Secondary Emergency Contact Phone Number
Secondary Emergency Contact Relationship to Client?
Please type name below as signature *
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