Union County, Ohio - UCATS - New Rider Form (Digital)

*First Name

*Last Name

*Address

*City

*Postal Code

*Cellphone

*Date of Birth

*Last 4 digits of SSN

*Gender

Male

Female

*Number in Household

*Monthly Individual Income

*Race

White

Asian

Native American

Black

Pacific Islander

Other

*Ethnicity

Hispanic or Latino

Not Hispanic or Latino

To ensure safe and appropriate service, please indicate all adaptive equipment that may require assistance

Cane

Walker

Wheelchair

Oxygen

House Ramp

Other

If you selected, "other", please explain below

Please indicate physical limitations that may require assistance/sensitivity

Hearing Loss

Vision Limitation

Seizure Disorder

Confusion

Other

If you selected, "other", please explain below

*Will the passenger require assistance from our drivers getting on/off the vehicle? If yes, will this require push/pull assistance from our driver?

Yes

If push/pull assistance is needed, please estimate the total weight being moved (Total Weight = Personal Weight + Equipment/Wheelchair Weight + Personal Items Weight) Approximate pounds.

If you have a wheelchair, please specify what type.

Manual Wheelchair

Motorized Wheelchair

Wheelchair Over 250lbs

*Emergency Contact Name

*Emergency Contact Relationship

*Emergency Contact Address

*Emergency Contact Cellphone

NEW RIDER RELEASE OF INFORMATION

The Ohio Department of Aging monitors the effectiveness of programs offered to Ohio senior citizens. The data collected (age, sex, race, low-income status, Activities, and Instrumental Activities of Daily Living) is forwarded to the Area Agency on Aging and the Ohio Department of Aging. The 1992 Older Americans' Act reauthorization requires this information to be summarized and reported to the Administration on Aging to keep state and federal legislators informed on the effectiveness of senior programs.

All information will be kept confidential and no personal identifying information will be released to the public without written consent, unless required under federal law.

Although all persons receiving services under the Older Americans' Act are asked to provide this information, no person may be denied services for refusing to provide any of the requested information.

Union County Human Services discloses information to transportation providers for the purpose of determining eligibility for cash assistance, medical assistance, and/or food stamp benefits, Senior Services Sales Tax Levy, or Ohio Department of Transportation Specialized Transportation for the following reasons: permission to verify information electronically, verbally, and in writing if a client is eligible for transportation.

I have read the Release of Information statement and understand that the information is reported to Administration of Aging, Union County Human Services, and other transportation providers. This authorization shall be in place until revoked by client. I have the right to revoke or cancel this authorization at any time by providing notice in writing to the following address: Union County Human Services, PO Box 389, Marysville OH 43040.

See UNION COUNTY AGENCY TRANSPORTATION SERVICE (UCATS) NEW RIDER INFORMATION for more information, terms, and conditions.

*I acknowledge and agree to the terms and conditions listed above, and I have completed the form to the best of my knowledge.

*Please print full first and last name to serve as a signature.

*Date of the signature.