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Access: Senior Transportation Registration Form
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 slash DD slash YYYY
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.
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