Applicants with Disabilities C-Tran Door-to-Door Registration Form

*Please Print Neatly*

All Door-to-Door applicants must go to the Cary Senior Center for photo.

Client Information:

Last Name:________________________________

First Name:________________________________

Middle Initial:______________________________

Demographics:

Gender______ Date of Birth:__________________

(F/M) (Month/Day/Year)

Disability Eligibility (only if under age 60):

Disability Description:________________________

Eligibility (circle one) Permanent Temporary

Eligibility Expiration Date:___________________

(Temporary Only)

Medicaid Number:__________________________

Do you require any of the following (circle yes or no)

Personal Assistant: YES NO

Wheelchair: YES NO

Service Animal: YES NO

Other:__________________________________

Until medical information on attached pages is filled out by medical professional, returned to C-Tran and verified by staff, you may not ride C-Tran’s Door-to-Door service.

NOTE: If you need to reserve your initial ride and schedule a pick up, please call (919) 481-2020, Dial Option #1.

TO BE COMPLETED BY STAFF ONLY:

Verified:

Residence c Staff____ ID Made c

Form Faxed c Staff____ Mailed ID c

Fax: 380-6426 Date:______

Received Medical Forms: c Staff____

Staff:________ Date:________

Client’s Primary Address:

Address:___________________________________

Apartment:________________________________

City:______________________________________

State:___NC_____ Zip Code:__________________

Home Phone (_____)_________________________

Cell Phone (______)_________________________

Work Phone (______)________________________

Fax (_____)________________________________

E-Mail Address:_____________________________

Emergency Contact Information:

Emergency Contact:_________________________

Relationship:_______________________________

Address:___________________________________

City:______________________________________

State: __________________Zip Code:___________

Phone (DAY) (______)_______________________

Phone (NIGHT) (_____)______________________

Cell Phone (_____)__________________________

This form should be completed in person at the Cary Senior Center OR faxed directly to: (919) 380-6426. For more, call (919) 469-4081.