Transportation Registration Fillable Form (PDF)

WATERFORD SENIOR SERVICES TRANSPORTATION PROGRAM REGISTRATION 
_________________________________ 
_________________________ 
 _____________ 
Last Name 
First Name  
      Date of Birth 
_______________________________ 
________________________         ____________ 
Address                                      Apt. #  
Town 
Zip Code       Phone Number 
Emergency Contacts: 
_________________________ 
_________________   
 ___________________ 
Name  
Relationship  
Phone Number 
___________________________ 
_________________ 
__________________ 
Name  
Relationship  
Phone Number 
Please describe your home’s exterior__________________________________________ 
Is the house number on the House or on the Mailbox? 
________________________ 
Please circle YES or NO for the following questions: 
1.
Do you have a disability?
YES 
OR 
NO 
2.
Can you climb (3) 12 inch steps?
YES 
OR 
NO 
3.
Do you have a companion who travels with you
who is able to assist you ?
YES 
OR 
NO 
4.
Do you live alone?
YES 
OR 
NO 
5.
Have you registered with Emergency Management letting them know that
you will need a ride to evacuate your home in an emergency situation or
that you rely on electrical power for your medical equipment? 
YES 
OR 
NO 
Please circle any of the following items that you use or conditions that pertain to you: 
1. I am: 
Hearing Impaired 
Visually Impaired 
Weak in the Legs 
2. I  use a: 
Walker  
Cane 
 
Portable Oxygen Tank 
3.  I use a: 
Wheelchair 
Electric Scooter 
Electric Wheelchair 
NOTE:  If you use any type of wheelchair or scooter, please complete the following: 
1.
Do you manage the wheelchair independently; or is there an
aide or family member that is physically able to assist you?
YES 
OR 
NO 
2.
If electric scooter or electric wheelchair, please give estimated weight of chair _____lbs.
OPTIONAL:  For the purposes of obtaining statistics for The State of Connecticut, please circle 
your racial origin:      
BLACK 
HISPANIC 
CAUCASIAN 
AMERICAN INDIAN/ALASKAN NATIVE 
ASIAN/PACIFIC ISLANDER 
(over please) 

Service Limitations 
Senior Services staff members will use their discretion to ensure that transportation requests can be provided 
safely. Senior Services may also refuse transportation to you if you engage in violent, seriously disruptive, or 
illegal conduct, pose a direct threat to the health and safety of others, are in possession of a weapon, display 
objectionable conduct (such as but not limited to being under the influence of alcohol or illegal drugs, or 
participate in any form of harassing behavior) or when the schedule is full.  Senior Services cannot assume 
responsibility for being a resident’s sole source of transportation. We advise all passengers to maintain family, 
friends, and neighbors as back up to the Senior Services transportation service. In order to have transportation 
available to all older and disabled residents, we may limit the number of rides scheduled per month per person 
if the demand for rides exceeds the department’s resources. Passengers are encouraged to register for the 
Municipal Transportation Grant program (MED RIDE), which provides transportation to medical appointments 
seven days a week and 24 hours per day in New London County and Westerly. 
Please read the description of the Waterford Senior Services Transportation Program and 
the following waiver and then sign and date below. Return this form to Senior Services. 
In consideration for participating in the above-referenced program/activity sponsored by the Senior Services Department of 
the Town of Waterford, I hereby waive and release the Town of Waterford, its agents, officers and employees, whether 
paid or voluntary, from and against any and all claims, suits, actions, damages, liabilities, costs, expenses and or judgments, 
including attorney’s fees and court costs, which may arise from my participation in the above-referenced program/activity 
or any illness or injury resulting there from, either directly or incidentally.  
I hereby represent that I have received, read, and understand the Waterford Senior Services Transportation Program policy 
and am familiar with the nature and type of activities in which I will participate as part of the above-referenced 
program/activity. I further represent that I am in good physical and mental health condition and that I am unaware of any 
physical or other health condition that would affect my ability to participate in the above-referenced program/activity. 
I acknowledge that I will be solely responsible for the furnishing of necessary safeguards and appropriate equipment for 
protection against injury. 
I have read this document and the document entitled Waterford Senior Services Transportation 
Program and understand and agree to the terms and conditions contained in both documents. 
__________________________________________    
     ___________ 
Client Signature 
Date 
__________________________________________        
     ___________ 
If applicable, Designated Facility Representative Signature 
Date 
The Town of Waterford upholds its commitment to the principles inherent in the 
Civil Rights Act of 1964, which affirms that discrimination is illegal. 
The Town of Waterford in accordance with Connecticut State and Federal law will ensure full compliance with Title VI of the Civil 
Rights Act of 1964 as amended and related statutes. The Town of Waterford is committed to ensuring that no person is excluded 
from participation, denied benefits, or otherwise subjected to discrimination under any program or activity or any service rendered to the 
public, on the basis of race, color, national origin, sex, age, or disability. 
 Further, the Town of Waterford prohibits discrimination in public accommodations on the basis of ancestry, breast feeding in a place of 
public accommodation, lawful source of income, learning disability, marital status, mental disability, mental retardation, physical 
disability, religious creed, sexual orientation, as well as using a guide dog/training a guide dog. 
To request additional information on The Town of Waterford’s non-discrimination obligations or to file a Title VI complaint, please submit 
your request or complaint in writing to: 
Lisa L. Cappuccio, Title VI Coordinator 
15 Rope Ferry Road 
Waterford, CT   06385 
Complaint forms can be obtained online at the Town of Waterford website www.waterfordct.org or in person at the Senior Services 
Department, Waterford Community Center, 24 Rope Ferry Road, Waterford, CT   06385