Access: Senior Transportation Registration Form

Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Home Phone
Cell Phone
Date of Birth*

Date Format: mm/dd/yyyy
Gender
- Male
- Female
Electronic Signature*
Please type your first and last name to confirm that you have you read this section and agree to the terms. Access: Senior Transportation is intended for Jewish individuals who live in Rhode Island. Individuals must be 65 years of age and older or have an ADA-recognized disability. This service does not currently accommodate wheelchairs. The cost to purchase each booklet is $10.00. Each voucher booklet contains 10 vouchers. Access: Senior Transportation is not an emergency service. If you need emergency assistance, call 911 immediately.
*
- I accept the terms.
I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above terms.