Erie County Senior Van Transportation Over 60 Participant Registration

Date

Last Name

First Name

Middle Initial

Date of Birth

Age

Street

City

State

ZIP

Telephone

Are you the spouse of another participant?

Yes

If Yes, who?

Do you receive Medicaid?

Yes

If Yes, CIN#

1 Person Monthly Income

Less than $1041

$1042-$1301

$1302-$1561

Greater than $1561

2 Person Monthly Income

Less than $1409

$1410-$1761

$1762-$2114

Greater than $2114

EMERGENCY INFORMATION

In case of an emergency, whom shall we notify?

Name

Address

City

ZIP code

Relationship

Phone

MEDICAL INFORMATION

Physician’s Full Name

Address

City

ZIP code

Physician’s Telephone Number

Please answer all of the following questions. The purpose is to gather basic characteristics about the people we serve. Answering the questions will NOT affect your eligibility for receiving services

Sex

Male

Female

Are you a USA Veteran?

Yes

Are you?

Married

Single

Widowed

Divorced

Number of people living in household (including yourself)

Do you live alone?

Yes

No, with spouse

No, with relatives

No, with non-relatives

Race/Ethnicity

White, not Hispanic

Hispanic or Latino

Black, Not Hispanic

Asian

American Indian/Alaskan Native

Native Haw/Pac Islander

Other…

Do you consider yourself frail/disabled?

Yes

A person who has a physical or mental disability which substantially limits one or more life activities

Do you use a wheelchair

Yes

I consent to the Erie County Department of Senior Services saving personal information provided by me or my authorized representative in the Statewide Client Data System maintained by the New York State Office for the Aging. This personal information may include, but is not limited to, medical records, employment records, government records, and any other information collected from me by Erie County Department of Senior Services.

I understand that this information is being collected to help in providing services and to identify other services which I may benefit from. I understand that the authority to provide these services and to collect my information for these purposes is found in the Older Americans Act and the New York State Elder Law.

I understand that, consistent with New York State's Personal Privacy Protection Law, my personal information will be treated as confidential and will not be disclosed without my further informed consent for disclosure.

I acknowledge that informed consent has been explained to me and that I understand the need for the information being recorded and that there are laws and regulations protecting the confidentiality of authorized information.

I understand that signing this authorization is voluntary. Refusal to do so may make it difficult to make referrals on my behalf. I have the right to revoke this authorization at any time, except to the extent that action has already been taken based upon this authorization, by writing to Erie County Department of Senior Services.

Electronic Signature Agreement

By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

I Agree

Date