Wufoo

Name * First Last
Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country

Please tell us wher you live so that we know were to pick you up
Gender *
Male Female
Date Of Birth * MM / DD / YYYY
Faith-Link services are available to Irondequoit residents 60 years of age and older.
Home Phone Number * ### - ### - ####
Alternate/Cell Phone Number ### - ### - ####
Your Email
Emergency Contact
Emergency Contact Phone Number ### - ### - ####
Medicaid Recipient *
Yes No

Please tell us if yo are on Medicaid.
Medicaid Number
Ridership Service *
Normal - 8 rides per month Extended - 16 Rides per month -

We offer all qualified riders 8 rides per month. If you choose the Extended option all rides over the inital 8 must be to a Chronic Treatment facility such as a Dialisys or Chemotheropy facility. You may be asked to provide a doctor's perscription for the extra rides.
Chronic Treatment Required

If you selected the need for Chronic Treament service, please tell us what treament you require & the facility you typically go to.
Services Required - Check all that apply
Need Escort Use walker or cane Wheelchair user Other disability or special needs - explain below
Special Needs & Comments

Please tell us anything that might be helpful for Faith Link drivers to provide you with personal and quity service.
How did you hear about Faith-Link
Do Not Fill This Out