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Silver Streak Senior Transportation
Group ID#___________________ Individual ID#_______________________
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Name: |
Age: |
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Address: |
City: |
Zip: |
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Major Cross Streets: |
and |
Gate # |
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E-mail: |
Phone#: |
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Do you have a cell phone? yes no |
Cell Phone#: |
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Emergency Contact |
Emergency Phone # |
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Do you have a computer at home? yes no |
Do you use a computer? yes no |
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What is your date of birth? |
Month: |
Day: |
Year: |
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Are you 60 years of age or older? yes no |
Do you have a driver’s license? yes no |
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Are you enrolled in OCTA ACCESS? yes no |
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Are you enrolled in any other transportation program? yes no |
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If so, which one? |
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Do you require a person care attendant or someone to travel with you? yes no |
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Do you use oxygen? yes no |
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Do you use a wheelchair? yes no |
Do you use a walker? yes no |
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Signature _______________________ Date ______________
Silver Streak is a program of Jewish Family Service/OC
_____________________________________________
Silver Streak
Senior Transportation
Release and Waiver of Liability and Indemnity
In consideration of my voluntary participation in a Jewish Family Service transportation program, I ___________________________ hereby agree to the following:
I hereby release, waive, indemnify and hold harmless Jewish Family Service of Orange County, its directors, officers, employees and volunteers from any loss, liability, and damage due to my voluntary participation in the transportation program.
I hereby assume full responsibility for the risk of the bodily injury, death or property damage.
I further agree that the foregoing release and waiver of liability and indemnity agreement is intended to be as broad and inclusive as is permitted by the law of the state of California, and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.
I have read and voluntarily sign the release and waiver of liability and indemnity agreement, and further agree that no oral representations, statement or inducements, apart from the foregoing written agreement, have been made.
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Signature of Rider Date
___________________________________________________ _______________
JFS Staff Title Date
Jewish Family Service of Orange County
1 Federation Way, Suite 220
Irvine, CA 92603-0714
949 435-3460
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Page 2 - Silver Streak Senior Transportition
Senior Transportation
Senior Transportation
Group Rider Application
Group ID#___________ Individual ID# _____________