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2. First Name
3. Last Name
5. Address1
7. Address2
9. City
10. State
11. Zip
13. Home Phone*
    type in home phone number
14. Cell Phone
    Type in cell phone if applies
16. Birth Date
    Month, day & year
17. Email Address
    Type in home email address
19. Emergency Contact #1*
    type in emergency contact name
20. Relationship*
    Type in how this person is related to you
22. Home Phone*
    Type in your home phone number
23. Cell Phone
    Type in their cell phone number or a second phone number
25. Emergency Contact #2*
    Type in a second emergency contact name
26. Relationship*
    Type in how this person is related to you
28. Home Phone*
    Type in your home phone number
29. Cell Phone
    Type in cell phone or a second phone number
33. Reason for Transportation*
    Type in if Medical, Handicapped, or Activity use
35. Allergies
    Type in any Drug Allergies, Food Allergies or Other Allergies
37. Physician's Name
    Type in your Physician's Name
38. Physician's Phone Number
    Type in your physicians Phone number
40. Physician's Address
    Type in Physician's address
42. Terms and Conditions of Human Services Transportation
    1. Any medical or scheduled transport is the extent of the ride. Only exception and must be requested and approved by the office before the ride (if the driver has time) to stop for prescriptions after a Medical Transport if absolutely needed. 2. If parking fees apply to your medical transportation, it is YOUR RESPONSIBILITY to pay for it. 3. For the health, safety and the welfare of all passengers and drivers of the City Vehicles, the Director of the Broadview Heights Human Services Dept. may require that passengers bring an aide who is able to provide assistance to any passenger who utilizes transportation services provided by the City of Broadview Heights. 4. The Human Services Department reserves the right to refuse service due to illegal/inappropriate activity.
44. Waiver and Release
    The undersigned does hereby waive, release and hold harmless and indemnify the City of Broadview Heights and the Broadview Heights Human Services Department, their organizers, officers, employees, agents and sponsors for any and all claims for damage of personal injury to me of loss of personal injury to me or loss of property that may be caused by any act or failure to act on the part of the City of Broadview Heights, the Broadview Heights Human Services Department property both real and personal and waive any and all specific notice of the existence of such dangerous conditions, if any. By participating in or attending any Human Services events and I agree to allow publication of any photograph taken of myself for advertising purposes. Please be advised that any information provided may be subject to public disclosure under the Ohio Open Records Law.
46. Electronic Signature*
    Type in your full name
47. Date*
    Type in the date
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49. 1. Receive an email copy of this form.
50. Email address

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51. Submit

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