Rider Registration - Freeport Community Services

Name*

First

Last

Date of birth*

Address*

Street Address City State Zip Code

Brief directions to your home:*

Mailing address, if different from above:

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code Country

Home Phone*

Cell Phone

Email*

Do you live alone?

Yes

No, I live with:

I live with

Special needs (walker, vision, hearing, service animal):

Can you enter & exit a vehicle unassisted? Car:

Yes

No

Truck:

Yes

No

WE CANNOT PROVIDE WHEELCHAIR TRANSPORTATION

Are you fully vaccinate against the COVID-19 virus?

Yes

No

Do you use any other FCS services? If so, which ones?

Emergency contact information:

Contact Name*

First

Last

Contact Phone*

Relationship

All registration information will be kept confidential and used by the FCS Transportation Program only.

I understand that this is a program using volunteer drivers who offer their time and vehicle to help our community.

I have read and agree to the attached guidelines on using the program.

I waive all claims of any type (including, but not limited to, personal injury) against FCS and their volunteers for any action or inaction associated with the FCS Transportation Program. In addition to waiving all claims of liability against the above named, I indemnify them from any claims of liability from me or on my behalf.

Applicant Name*

First

Last

Signature*

You may also print and email completed form to ccryvoff@fcsmaine.org, or mail toCathy Cryvoff, AFFP Coordinator, Freeport Community Services, PO Box 119, Freeport, ME 04032.Please call (207) 865-3985 x222 with any questions.