Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Gender *

Male

Female

Nonbinary

Assessment (Check all that apply) *

Note: UCAN is unable to transport wheelchair bound clients.

I use a cane

I use a walker

I can get into and out of a car with minimal assistance

I can get into and out of a minivan or SUV with minimal assistance

I need assistance walking into the appointment

Transportation Guidelines *

UCAN volunteers give their personal time to provide all services of the organization. For this reason, the following guidelines are expected of clients receiving UCAN services. By checking each box, you have read and agree to the UCAN Guideline

I will treat UCAN volunteers and staff in a courteous, respectful manner

I will give at least a week's notice when requesting transportation.

I understand there is a two ride per week limitation, with a maximum of a three-hour duration

I will not ask to add on any stops

I will give ample notice to cancel my scheduled rides whenever possible. I understand if I routinely cancel trips without notice, this will result in termination of services.

Agreement of Services *

I understand that UCAN reserves the right to refuse service at any time. Our number one concern is the safety of those we are driving and our volunteers. I understand that misrepresentation or omission of facts requested in this application is cause for rejection as a UCAN client. By checking the box, I understand that failure to comply with these procedures may lead to termination of services.

I accept UCAN's policies