TASC Rides Passenger Registration FormPlease read and complete this registration in its entirety. Any information provided is confidential and will only be shared with your permission. Please call us if you have any questions. Mail this completed form to TASC, Hobbs House Community Center, 200 High Street, Hampton, NH 03842. Passenger's Name * The name of the person needing transportation. First Name Last Name Passenger's Date of Birth * MM DD YYYY Passenger's Home Address * Where will the passenger be picked up? Please list any apartment or unit numbers as necessary. Address 1 Address 2 City State/Province Zip/Postal Code Country Passenger's Mailing Address (If Different) Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Home/Primary Phone * You must provide TASC with a current phone number to confirm rides. This can be a friend or relative if absolutely necessary. If we can’t confirm the ride with you, we can’t provide it to you. (###) ### #### Alternate/Cell Phone (###) ### #### I understand that the Passenger and Volunteer Drivers are required to wear face coverings that cover the nose and mouth. * If a face covering cannot be worn, you cannot get a ride. I understand Why does passenger require transportation assistance? * Select all that apply Passenger no longer drive/Passenger never drove (applies only to passengers aged 55 and over) Passenger have a disability that prevents me from driving Other, I will specify If Other Please Specify (i.e., recent surgery, medical condition, etc.) I understand that Passenger must be able to get to and from a volunteer’s vehicle with little or no assistance. * If Passenger cannot do so, a responsible adult will accompany the passenger. Passenger understands that TASC volunteer drivers cannot do anything more than provide a steadying hand I understand I understand that volunteer drivers cannot sign any forms assuming responsibility for passenger care. * They are able to confirm to a medical practice that they are providing a ride. I understand Do you have any equipment that you will bring with you, for example, a walker or oxygen? * They are able to confirm to a medical practice that they are providing a ride. No Yes, I will list below I will have the following medical equipment with me: Are you able to get into a truck, van, or SUV with little or no assistance? * You need to be able to get yourself into the vehicle unassisted. TASC Volunteer Drivers are unable to provide anything more than a steadying hand. Yes No Are you able to sit in the back seat of a vehicle? * Yes No Do you have a Seeing Eye Dog or service animal that will accompany you? * You need to be able to get yourself into the vehicle unassisted. TASC Volunteer Drivers are unable to provide anything more than a steadying hand. No animal Seeing Eye Dog Service Animal, I will specifiy below I will have the following service animal with me: * On most occasions, will you be the only passenger? * Yes, I will be the only passenger No, Passenger will have their child* No, Passenger will have an additional adult.** *Passenger understands that children under the age of 18 must be accompanied by a parent/guardian/legally responsible caregiver who is an eligible passenger registered with TASC. Please refer to our Policies and Procedures for details. Yes **Passenger understand an additional adult must complete their own registration Yes Is there anything else that affects passengers ability to travel that we should know? * No Yes, I will explain belwo The following affects my ability to travel: TASC often works with other agencies such as, but not limited to, the American Cancer Society, the Disabled American Veterans, and Medicaid to fill transportation requests. If appropriate, may we share your contact information with other agencies? * Yes No - A "no" response will NOT prevent eligible passengers from using TASC RIdes Services. Emergency Contact Passenger's Emergency Contact - Please fill it out completely. Emergency Contact * First Name Last Name Relationship To You * Emergency Contact's Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact's Phone * (###) ### #### How did you learn about TASC? * Brochure Friend Family Clergy County Office VA State Office Town Office Web Search Advertising TASC Rides Worker Home Health Agencfy Medical Office Other, will specify If other please specify: * Passenger was Referred By: Residents 55+ or adults with a medical challenge or disability that prevents driving, from one of the towns we serve are eligible. If you are under 55, you must provide a name and phone number of a referral, for example, a doctor or visiting nurse. TASC must verify that the need for transportation is based on a disability or medical condition. Motor vehicle offenses/loss of license are not qualifying disabilities or medical conditions. Name of person referring passenger: First Name Last Name Phone number of referring entity (###) ### #### Are you a United States military veteran? * Yes No Passenger's Gender * Female Male Non-Binary Other Preferred Pronouns Would you like to receive information about TASC’s special events & fundraising efforts? Yes No Your Digital Signature is Required by certifying the boxes below: I/Passenger have received, read, and will follow TASC’s Policies and Procedures. * I/Passenger understand that TASC does not guarantee a volunteer driver will be available for all rides. * I/Passenger understand and expressly assume all risks inherent in motor vehicle transportation. Please Type your full name. * I hereby declare that all the information provided in this application is true and accurate to the best of my knowledge. Today's Date * MM DD YYYY Thank you!
