Application for Community Bridges - Lift Line
* Required
Applicant Information
First Name
*
Middle Name
Last Name
*
Date of Birth
*
MM slash DD slash YYYY
Home Phone Number
*
Cell Phone Number
Email Address
*
Are you a Veteran?
Yes
No
Preferred Language
English
Spanish
Other
Specify Language
Pick Up Address (Where You Will Be Picked Up For Transportation)
Current Home Address
*
City
*
State
*
ZIP Code
*
Please select one:
House
Apartment Complex
Mobile Home Park
Nursing Home
Other
If other, please specify:
Mailing Address (If Different From Pick Up Address)
Mailing Address
City
State
ZIP Code
Emergency Contact
Name of a Relative
*
Relationship
Home Phone Number
*
Cell Phone Number
Address
City
State
ZIP Code
Demographics
Ethnicity
Caucasian
African-American
Latino
Asian
Native American
Pacific Islander
Other
If other, please specify:
Annual Household Income
Household Size
Sex
Male
Female
NA
Transportation Information
Are you ambulatory (able to move around)?
Yes
No
Do you use a wheelchair?
Yes
No
Size of wheelchair?
Are you able to transfer?
Yes
No
Do you use any type of aids?
Walker
Cane
Service dog
Other
If other, please specify:
Disability type:
Alzheimer
Dementia
Hearing impaired
Mental disability
Physical disability
Stroke
Visual impairment
Other
If other, please specify:
Required Documents/Verification
Income verification (please upload copy)
Income Tax
Social Security
Other
If other, please specify:
File upload (income verification)
Allowed file types (PDF, DOC, DOCX, ODT, JPG, JPEG, PNG). Maximum 3 files (3MB each).
Drop files here or
Select files
Accepted file types: pdf, doc, docx, odt, jpg, jpeg, png, Max. file size: 3 MB, Max. files: 3.
Are you under the age of 60?
Yes
No
If you are under the age of 60, you will need to provide proof of disability with your application:
Doctor's note
ParaCruzID
State Disability
Other
If other, please specify:
File upload (proof of disability)
Allowed file types (PDF, DOC, DOCX, ODT, JPG, JPEG, PNG). Maximum 3 files (3MB each).
Drop files here or
Select files
Accepted file types: pdf, doc, docx, odt, jpg, jpeg, png, Max. file size: 3 MB, Max. files: 3.
Please complete the following if person other than applicant filled out the application
Name
Title
Relationship to client
Signature (type full name)
Date
MM slash DD slash YYYY
Signatures
By signing below I certify that the information contained herein is accurate to my knowledge.
Print Name
Date
MM slash DD slash YYYY
Signature of applicant (type full name)
CAPTCHA
Click the SEND button only once. It may take a few seconds for the form to be submitted. You will see a confirmation message when the form has been received.
Comments
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