Med Ride Application FY25

Municipal Medical Transportation Service 
TRANSPORTATION ELIGIBILITY FORM 
Name :( please print) __
 Birth Date_ 
/ 
/
 
Address: _ 
City  
Zip Code  
Telephone #  
Please describe your home’s exterior 
Is the house number on the house or mailbox? __ 
  No 
  No 
Do you have a physical disability?  Circle one.                                        Yes  
Do you have a mental disability or cognitive impairment? Circle one.    Yes        
Do you have Medicaid as a form of insurance?  Circle one                        Yes    
  No 
Note:  Individuals under the age of 60 must provide proof of their disability from the Social Security 
Administration. 
Do you use a mobility aid?  I.e. wheelchair, walker, cane, scooter? Please list. 
___________________________________________________________________________________ 
Can you get into a car unassisted?   
Circle one!
Yes          No        
Emergency Contact information: 
Name 
Address: _ 
Telephone #
 

Please mail or deliver the completed form to:
Waterford Senior Services 
24 Rope Ferry Rd.  
Waterford, CT 06385 

To minimize abuse, all trips are subject to random audit.

Service is not available to Nursing Homes.
We reserve the right to deny transportation to any individual who does not meet the criteria for the 
transportation program.  
I have read and understand the guidelines of the municipal medical transportation service, which is attached. 
 
__________________________ 
Client Signature 
Date 
2024-2025