SILVER KEY TRANSPORTATION REGISTRATION

Date: ______

Name: (Last) ______(First) ______(MI) ______

Age:______DOB: ______SS#: ______-__ __-______Gender: MALE FEMALE

Address: ______Apt #:______

City: ______State: ______Zip: ______

Name of Complex: ______Phone: ______

Mailing Address (If different from above): ______

City: ______State: ______Zip: ______

Are you: ___Elderly (60 and above) ___ Disabled (59 and under) ___ Frail

ADA Certified: __ YES __ NO Certification Number: ______Expiration Date: ______

Disability: __ Cancer__ Kidney Failure__ Amputation__ Arthritis

__ Brain Injury__ Dementia__ Seizure Disorder__ Multiple Sclerosis

__ Parkinson’s disease__ Stroke__ Hearing Impaired__ Vision Impaired

__ Spinal Cord Injury__ Temporary Disability__ Mental Condition (PTSD, Autism, etc.)

__ Heart Conditions__ Diabetes__Alzheimer’s__ Other:______

Race:

__ Caucasian__ Asian__ Hispanic__ African American__ Native American__ Hawaiian or Other

Are you a Veteran?__ Yes__ NoWhat is your primary language? ______

Do you live alone? __ Yes__NoHow many people live in your household? ______

If you live alone, is your individual income below $1,005?__ Yes__ No

If you have a spouse or partner, is your monthly household income below $1,353?__ Yes__ No

Medicaid:__ Yes__ NoMedicaid HCBS: __ Yes__ NoMedicaid #: ______

Emergency Contact: ______Phone: ______

Relationship: ______

Silver KeyTransportation Registration Cont’d.

Mobility Status

Space type: __ AMB__ Lift__Wheelchair WC Type: Manual Powered Scooter

Mobility Aides: __None__Cane__Crutches__Oxygen__Walker__White Cane

Will you need additional assistance at all times: __ Yes__ No

(ex. Help with mobility aid, door through door service, or help up and down stairs?)

Explain: ______

Will you have a Caregiver ride with you?__Yes__NoService animal?__Yes__No

Do you have vision problems?__ Yes__ NoDo you wear eyeglasses?__ Yes__ No

Do you have hearing problems? __ Yes__ NoDo you use a hearing aid?__ Yes__ No

Please note any serious medical conditions: ______

Referral Requested:__ Yes__ NoType:__Care Mngt.__ Nutrition__ Health Equip __ Other

How did you hear about our services? ______

NOTES______

Prepared by: ______Date: ______