Transportation Services Application

Last Name *

First Name *

Date of Birth *

Gender *

Male

Female

Street Address *

City *

Zip Code *

Home Phone *

Mobile Phone

of Drivers in household *

E-mail

Nearest Cross Streets *

I am in need of transportation through Bloomfield Township Senior Services because of the following medical conditions or reasons I cannot drive: *

I will use this service for: *

Select as many transportation needs you have.

rehab

to BTSS

dialysis

medical/dental appts.

I will use this service approximately: *

Select the frequency you anticipate using the service.

weekly

monthly

quarterly

other

Other *

Describe how often you need the service.

I am handicapped and will need a wheelchair van for transportation *

Yes

No

Monthly Income (ONLY applicable if requesting financial assistance)

Emergency Contact Name *

Emergency Contact Phone *

Relationship *

Emergency Contact Email Address

Emergency Contact Mobile Phone

I certify that I am a resident of Bloomfield Township or the City of Bloomfield Hills and that the above information is accurate, true, and complete to the best of my knowledge. I understand that I am responsible for a 45% co-payment for medical transportation only through BTSS contracted services and agree to pay monthly invoiced amounts. I agree to pay fees associated with transportation to Bloomfield Township Senior Services.

Agreement *

Check to agree to the above statement.

Typed Signature *

Enter your typed signature.

Today's Date *

By submitting this form, the parties agree that this agreement is the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.