STEP 1 OF 3 Client Information and Release Form *Client Name: *Phone Number: Street Address: Mailing Address: State: City: ZIP: Race: Birth date: E-mail: NEXT STEP 2 OF 3 Do you live with someone? Yes No Will someone accompany you to your appointment? Yes No If so, who? Do you have any limitations? Please circle what applies: Cane Walker Wheelchair Oxygen Vision None NEXT STEP 3 OF 3 EMERGENCY CONTACT INFORMATION: *Name: Relationship: Address: City: State: Zip: Home Phone: *Cell Phone: E-mail: Comments: Payment Method ($50 Annual Membership): Send a check made out to "Nutmeg Senior Rides" to: Nutmeg Senior Rides, PO Box 448 East Windsor, CT 06088 If you have any questions, please call Margaret Smith Hale, Executive Director, at 860.758-7833 or email ctseniorrides@gmail.com CONTINUE By clicking “Continue”, you agree to our Terms and Conditions and Privacy Policy.
