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Urbandale Community Action Network

Urbandale Community Action Network

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Senior Client Application


Gender
Do you have durable power of attorney for healthcare situations?
LimitationsCheck all that apply
Do you use any of the followingCheck all that apply. NOTE: we cannot transport wheelchair bound clients
Do you have a valid drivers license?
Does anyone in your household drive?
Can you get into and out of a car with minimal assistance?
Can you get into and out of a minivan with minimal assistance?
Do you need assistance walking to the appointment once driven there?

Grocery Shopping/Errands

Please check all that apply
Do you tire easily while shopping?
Do you need assistance while in the store?
Do you need help carrying in groceries and putting away?

Form Section

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.

  1. Treat UCAN volunteers and staff in a courteous, respectful manner
  2. Give as much notice as possible when requesting services. (2 ride/week limit, 3 hours max duration per trip.)
  3. Do not ask to add on stops after being picked up - plan your trip and tell the scheduler so we can accommodate your needs.
  4. 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?

The Urbandale Community Action Network (UCAN) is a 501(c)(3) nonprofit organization citizen group providing leadership and ongoing support for comprehensive community-based action to improve the quality of life in Urbandale.

Mailing Address: UCAN P.O. Box 7615
Urbandale, IA 50323

Administrative Office: 3600 75th St. Urbandale, 50322

PHONE: (515) 334-2632
FAX: (515) 278-3931

[email protected]

UCAN adheres to the USDA Non-Discrimination Policy

https://www.usda.gov/non-discrimination-statement

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