Please complete and submit this form, and we will contact you very soon. Answering the short list of questions will allow us to customize our response.
Fields with an asterisk (*) are required.
I am inquiring for:
myself
relative
friend
neighbor
*
The program I am inquiring about is:
Select Program
Taxi Discount Program
Wheelchair Transport
Volunteer Medical
Grocery/Shopping Shuttle
*
I am interested in volunteering as:
A Driver
Office Assistance
Other
Please complete the Question/Comment section listed below:
Name:
*
Address:
*
City:
*
State:
*
ZIP:
*
Daytime Phone:
*
E-Mail:
*
NOTE: The Volunteer Medical Transportation Program needs more volunteer drivers. We use voice page units, reimburse mileage and provide secondary auto insurance. Volunteers create their own flexible schedule for providing this transportation service. Make a difference.... by enabling senior citizens to maintain a healthy, independent lifestyle.
