Applicants for Seniors (60+) 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)

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

Personal Care Attendant: YES NO

Wheelchair: YES NO

Walker: YES NO

Oxygen: YES NO

Service Animal: YES NO

Other:______________

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

Age c Staff____ Date:______

Form Faxed to C-Tran 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. For more, call the Cary Senior Center (919) 469-4081.