Senior Client Application – Urbandale Community Action Network

Name

Email Address

Phone

Cell Phone

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

GenderMaleFemale

Date of Birth

Languages Spoken

Emergency Contact Name

Phone

Relationship to you

Do you have durable power of attorney for healthcare situations?YesNo

Name

Phone

Healthcare concerns

Please explain

Do you use any of the followingCaneWalkerCheck all that apply. NOTE: we cannot transport wheelchair bound clients

Do you have a valid drivers license?YesNo

Why do you require our services?

Why did your license lapse?

Please list anyone you live with & their relationship with you.

Does anyone in your household drive?YesNo

Can you get into and out of a car with minimal assistance?YesNo

Can you get into and out of a minivan with minimal assistance?YesNo

Do you need assistance walking to the appointment once driven there?YesNo

Grocery Shopping/Errands

Please check all that applyRegularly scheduledIntermittent Requests onlyI will go to the store with volunteerI would like a volunteer to assist with online ordering

Do you tire easily while shopping?YesNo

Do you need assistance while in the store?YesNo

Do you need help carrying in groceries and putting away?YesNo

Please indicate day/time of routine weekly appointments, if any, that require transportation in text box below

Form Section

Is there anything our volunteers should be aware of while assisting you that has not been addressed above? Please explain

How did you hear about UCAN/Urbandale Caring Corps?

Transportation Guidelines

UCAN/Caring Corps Volunteers give their personal time to provide all services of the organization. They receive no compensation for the time or expense incurred during their volunteer time. Without a large, vibrant volunteer force, our organization would not be able to provide any services. For these reasons, the following guidelines are expected of clients receiving UCAN/Caring Corps services.

Treat UCAN volunteers and staff in a courteous, respectful manner
Give as much notice as possible when requesting services. (2 ride/week limit, 3 hours max duration per trip.)
Do not ask to add on stops after being picked up - plan your trip and tell the scheduler so we can accommodate your needs.
Give ample notice when cancelling a trip is unavoidable but do my best to keep all scheduled rides- cancellation of trips without notice will result in termination of services.

We reserve the right to refuse services at any time. Our number on concern is the safety of those we are driving and our volunteers. If you have a medical condition that is unregulated or requires assistance above what our volunteers can provide, we will refer you to other transportation services such as Paratransit, DART, or private transport companies.

I have read, understand and agree to UCAN Client Guidelines.

I understand that I must be officially accepted before becoming a client. I understand that misrepresentation or omission of facts requested in this application is cause for rejection as an Urbandale Community Action Network (UCAN) client. I understand that failure to comply with these procedures may lead to termination of services.

Do you agree to the above guidelines?I agreeI do not agree

Please enter your full name as a signature