New Client Application – English

Client Application Instructions

Complete the entire application. If you have any questions or do not understand any of the questions on the application call 205-978-1000 for local residents or 1-800-543-7143, and press option #1. Applications will be processed within two weeks from the date they are received.

If you need to download a PDF version of the form, please click here .


Name
First Last

Date of Birth
/ /
MM               DD                YYYY

Gender

Address
Street Address
Address Line 2
City State / Province / Region
Zip / Postal Code Country

Social Security #

Medicaid #

Home Phone
- -
(###)            ###              ####

Cell Phone
- -
(###)            ###              ####

Work Phone
- -
(###)            ###              ####

May we call you at work

Do you or a family member speak English

Special Needs:
 Wheelchair Medical Equipment Other

Statistical Information:
Because of the generosity of our valued donors, Kid One is able to provide transportation services for needed medical appointments. Often these donors request statistical information for reporting purposes and validation of services. Information you provide will not be a determining factor regarding your eligibility and information will be kept confidential.

Race/Ethnicity

Type of Appointment

Diagnosis

What type of insurance do you have?

Are you a prenatal patient

If so, what is your due date?
/ /
MM               DD                YYYY
*Prenatal clients only qualify for 1 postpartum appt.

Name of Client (2)
The following information pertains to the client, the individual receiving the transport

Name
First Last

Date of Birth
/ /
MM               DD                YYYY

Gender

Race

Social Security #

Medicaid #

Special Needs:
 Wheelchair Medical Equipment Other

Type of Appointment

Diagnosis

What type of insurance do you have?

Are you a prenatal patient

If so, what is your due date?
/ /
MM               DD                YYYY
*Prenatal clients only qualify for 1 postpartum appt.

Name of Client (3)
The following information pertains to the client, the individual receiving the transport

Name
First Last

Date of Birth
/ /
MM               DD                YYYY

Gender

Race

Social Security #

Medicaid #

Special Needs:
 Wheelchair Medical Equipment Other

Type of Appointment

Diagnosis

What type of insurance do you have?

Are you a prenatal patient

If so, what is your due date?
/ /
MM               DD                YYYY
*Prenatal clients only qualify for 1 postpartum appt.

Name of Parent/Legal Guardian
First Last

Relationship to client

Date of Birth
/ /
MM               DD                YYYY

Special Needs:
 Wheelchair Medical Equipment Other

Name of responsible adult accompanying the client to appointments
First Last

Relationship to client

Date of Birth
/ /
MM               DD                YYYY

Special Needs:
 Wheelchair Medical Equipment Other

Transportation Need
At Kid One, we are focused on fulfilling our mission effectively and efficiently. Our commitment is to provide quality service for families in Alabama who have no means of transportation in reaching needed medical care. We are able to provide this service because of the financial support of local communities, and our concentration is to serve those with the greatest need. Along with this support and commitment comes a responsibility to our clients, donors, volunteers, and team members.

Do you have access to transportation

If not, why?
What other options for transportation are available in your area (e.g. buses, taxis, friend’s vehicle, etc.)

Referral Information

How did you learn about Kid One Transport services?

If you are a referring party, please complete the section below
First Last

Relationship to client

Agency Name

Phone Number
- -
(###)            ###              ####

Alternate Phone Number
- -
(###)            ###              ####

Email

Household Income

Limited Power of Attorney for Medicaid Reimbursement

I, the undersigned, have made, constituted, and appointed, and by these presents do make, constitute and appoint Kid One Transport ("Kid One") as my true and lawful Attorney ("Attorney") with full power of substitution to do the following in my name, place, and stead:

To receive, take, endorse, assign, deliver and negotiate any check or other commercial paper made payable to myself representing reimbursement for transportation services provided by Kid One to myself and/or my children and/or dependents and I hereby ratify and approve all such prior acts taken by Kid One. I understand that certain banking or other financial institutions shall rely upon this limited power of attorney to deposit said checks, made payable to myself, to the account of Kid One and I hereby absolve and hold any such bank or financial institution harmless from any and all claims or liability for depositing said checks or commercial paper described herein which are presented by Kid One for deposit to the account of Kid One. Any banker or financial institution may rely upon this limited power of attorney until notified in writing that it has been revoked.

My mental and physical ability subsequent to my execution of this Limited Power of Attorney shall not revoke said power which shall remain in full force and effect notwithstanding said mental or physical ability. These presents shall extend to and be obligatory upon the executors, administrators, legal representatives, and successors, respectively, of the parties hereto.


IN WITNESS WHEREOF, I have hereunto affixed my signature this day of
/ /
MM               DD                YYYY

Printed Name of Person Receiving Transport (Client)
First Last

Printed Name of Parent/Guardian (required if Client under the age of 19)
First Last

General Release

I understand that Kid One Transport System ("Kid One") is a non-profit agency that provides transportation to healthcare related facilities or providers for expectant mothers and children who, due to a lack of transportation, would otherwise be unable to reach the facility or provider.

In exchange for the transportation provided by Kid One, I on behalf of myself, and for my heirs, executors, administrators, and assigns and as the parent or legal guardian of the child listed below, do hereby: (1) assume full responsibility for utilizing the transportation services provided by Kid One, and (2) release, acquit, forever forgive, discharge and hold harmless Kid One, its successors and assigns, employees and agents and each of their heirs, executors and administrators, and all other persons, firms and corporations, from any and all claims, demands, rights and causes of action, of any kind and nature, in law or in equity, arising from or in connection with the transportation provided to me and/or my child by Kid One.

By my signature below, I acknowledge: (1) that I am nineteen (19) years of age or older, (2) that I am the parent or legal guardian of the child identified below, (3) that I have authority to enter into this Release on behalf of myself and the child identified below, and (4) that I have carefully read this Release and fully understand and know the terms thereof, and sign the same as my own free act.

Failure to comply with the rules and regulations set forth by Kid One will result in termination of service. Kid One Team Members reserve the right to refuse transport services at any time for any reason.

Kid One Transport is not responsible for any items left by clients in the transport vehicle.


Signature of Parent/Legal Guardian
First Last

Date
/ /
MM               DD                YYYY

departs from Port Canaveral, Florida and takes you to four different ports of call where you can go on brief land excursions Labadee, Hispaniola; Ocho Rios, Jamaica; steve atwater 3xl jersey George Town, Grand Cayman; Cozumel, Mexico before you cruise back to Port Canaveral in Florida. The Voyager of the http://scoop.hoosiershq.com/ Seas lets you start your Caribbean vacation travel cruise fun in Miami, Nike NFL Houston Texans Florida, and Cameron Heyward White Jersey making http://www.fastinfo.com.au/ brief stops in Hispaniola, Jamaica, Grand Cayman, and Mexico. The ship offers http://subsex.dk/blog/ you four Daniel Kilgore Jersey kinds of room accommodations, ranging from $549 Russell Wilson Youth Elite Jersey to $2,049.00. Other midsize ships mean a more spacious and comfortable Caribbean vacation travel cruise, with all the service and amenities you expect, but no waiting in long lines for meals authentic olivier vernon mens jersey or port of http://kanizsa2.szuperinfo.hu/2015/09/15/cheap-jerseys-wholesale-nba-jerseys-free-shipping-3ss27-wholesale-jerseys-from-china/ calls. Muhammad Wilkerson Green Jersey Three http://socialmediasun.com/ Night Enchantment or Four Night Excitement Few places on earth are more conducive to relaxation than http://www.utiwa-go.com/blog/repo/2015/09/15263.html the islands johnny manziel xl jersey of the Caribbean. Perhaps, it the light, tropical breezes that gently soothe the soul. Or the warm waters and warm womens jacquian williams limited jersey http://www.alexkuo.info/ receptions tat http://lifeandstyle.ca/cheap-jerseys-wholesale-jerseys-free-4qp095-wholesale-jerseys-from-china/ await you on every shore. One authentic sharrif floyd womens jersey thing is certain: aboard a Celebrity
chairman of Terranova Corp Stephen H. Bittel, chairman http://auto.ferrari.com/ of Terranova Corp., has reached new heights in the realm of commercial real estate since his firm’s $342million sale of a portfolio of http://www.thomasverbeek.com/blog/ six buildings on Lincoln Road in pierre garcon jersey Miami Beach one of the http://www.altadill.com/cheap-jerseys-cheap-jerseys-free-2dn075-wholesale-jerseys-from-china largest property deals http://www.ifb.org.bn/?p=218 in South Florida history. Terranova remains an owner http://avangard-tour.com/?p=518 and managing mens joplo bartu limited jersey member of the properties, in a http://www.arysutacenter.com/cheap-jerseys-wholesale-nfl-jerseys-free-5qh673-wholesale-jerseys-from-china/ new partnership with Morgan Stanley Real Estate http://www.largerpie.org/china/cheap-jerseys-cheap-jerseys-from-china-free-2ap511-wholesale-jerseys-from-china/ Investing. In http://www.bodycopy.es/?p=600 total, Terranova Corp., which Bittel founded in 1980, owns and womens miles burris game jersey operates more than $1 billion http://cfiindia.com/?p=367 of real estate in Florida, mostly http://www.ilpiazzaledelleaste.it/?p=595 in South Florida. Stephen H. Bittel, chairman of Terranova Corp., has reached new heights in the realm of commercial real estate mens jamesmichael johnson elite jersey since his firm’s $342million Mark Sanchez l authentic jersey sale of a portfolio of six luke willson pink jersey buildings http://www.tapscape.com/ on Lincoln Road in Miami Men’s Peyton Manning Game Grey Shadow Jersey Beach one of the Louis Delmas Green Jersey largest property deals in South Florida history. Terranova remains an Teddy Bridgewater Road White Men’s Game Jersey owner http://minus-9.com/ and managing member of the properties, in a Teddy Bridgewater Pink Women’s Elite Jersey new partnership with Morgan Stanley Real Estate Investing. In total, Terranova Corp., which Bittel founded in 1980,
1933, 1945, 1957, 1969, 1981, 1993, 2005) as per Chinese Astrology, know how replica oakleys you will fare in 2006 in your Career/Business, Health, http://www.ghenera.com/?p=517 Wealth, Harmony and Love. Be aware of your strengths and be warned of the negative energy that you may have to face, to plan your strategies well ahead. Get to know the Fengshui Enhancers and Cures that can help you, too. Annual Forecasts Fengshui Remedies for 2006 : Year of the Yang Red Fire Dog for Pig Sign If you were born in the Year of Pig or Boar or Hog (1911, 1923, 1935, 1947, 1959, http://tracabilite.akare.eu/cheap-jerseys-cheap-jerseys-from-china-free-7ty289-wholesale-jerseys-from-china 1971, 1983, 1995) as per Chinese Astrology, know how you will fare in http://nbbcmiami.org/cheap-jerseys-cheap-nike-jerseys-free-shipping-3ec67-wholesale-jerseys-from-china/ 2006 in your Career/Business, Health, Wealth, Harmony and Love. Be aware of your strengths and be warned of the negative energy that you may have to face, to plan your strategies well ahead. Get to know http://mediakompass.ro/?p=510 the Fengshui Enhancers and Cures that can help you, too. Flying Stars Fengshui http://a32.me/ for 2006 http://www.favorednations.com/cheap-jerseys-wholesale-nba-jerseys-free-shipping-7fm94-wholesale-jerseys-from-china/ : Yearly Predictions Remedies for Main Door facing North If the Main Door of your flat/office/building faces North,
che veste http://susukambingboncah.com/cheap-jerseys-cheap-jerseys-from-china-free-3be370-wholesale-jerseys-from-china/ e diverte Si tratta della classica polo in cotone, con due bottoncini e il "collo a maglia", con i classici spacchi laterali che permettono eventualmente di indossarla anche fuori dai pantaloni http://ALLABOUTACIDREFLUX.INFO/cheap-jerseys-cheap-jerseys-from-china-free-4nt240-wholesale-jerseys-from-china/ per un look più https://www.supplyinglondon.com/?p=1015 sportivo. Nella foto è riportato il colore celeste http://www.abplus.lu/actualites/cheap-jerseys-wholesale-nfl-jerseys-free-2xh854-wholesale-jerseys-from-china/ a righe orizzontali che ho visto ed è davvero bello ed elegante. Nell’etichetta c’è scritto che si può lavare al massimo http://www.jomfruholmen.no/2015/09/cheap-jerseys-wholesale-jerseys-from-china-free-8lx410-wholesale-jerseys-from-china/ a 40C. Io vi consiglio di lavarla http://www.crhideas.com/ al massimo a 30C in http://healingandgrowth.com.au/cheap-jerseys-cheap-nfl-jerseys-free-0qo925-wholesale-jerseys-from-china/ modo da non rovinare i colori e non farli sbiadire. Se poi la lavate in lavatrice utilizzate il programma dei http://medvoy.com/blog/cheap-jerseys-cheap-wholesale-jerseys-free-shipping-2hy17-wholesale-jerseys-from-china/ delicati, altrimenti lavatela a http://discover-places.com/mahout/cheap-jerseys-cheap-jerseys-free-6se669-wholesale-jerseys-from-china/ mano con un po’ di sapone per delicati. In questo modo http://unrepentantindividual.com/ vi http://crowdsourcetesting.com/ durerà di più http://cnacareer.org/ e non altererete i colori. La maglietta può essere indossata sia in estate che in inverno se non http://www.productionservicesfrance.tv/tvonlyinternational/cheap-jerseys-wholesale-jerseys-free-0db509-wholesale-jerseys-from-china/ siete freddolosi. Inoltre si abbina bene sia con un paio di jeans che con pantaloni meno sportivi con una giacca casual. La potete acquistare nei negozi sportivi, http://takeipod.com/news/cheap-jerseys-wholesale-jerseys-free-7hr471-wholesale-jerseys-from-china/ oppure negli store
Agency Virus Protection Must http://cedice.org.ve/?p=22416 Include System Backup In his nearly 25 years in the advertising/public relations field, Andy has been involved with a broad range of http://serenapools.com/ corporate and http://www.deepmarket.com/business-intelligence/cheap-jerseys-cheap-jerseys-free-shipping-8hl92-wholesale-jerseys-from-china/ marketing activities. Prior to forming Marken Communications in mid 1977, Andy was vice president http://www.tapscape.com/ of Bozell Jacobs and its http://en.dev.oyafestivalen.com/2015/09/16/cheap-jerseys-wholesale-jerseys-free-4ry491-wholesale-jerseys-from-china/ predecessor agencies. During his 12 years with these agencies, he developed and coordinated http://www.golfnw.com/hot-golf-stories-from-other-wirters/cheap-jerseys-wholesale-jerseys-free-0ck402-wholesale-jerseys-from-china/ a wide variety of highly visible and successful promotional campaigns and activities for clients. A graduate of Iowa State University, Andy received his Bachelor Degree with majors in Radio Television and Journalism. Widely published in the industry and trade press, he is an accredited member of the Public Relations http://www.giovannirana.com/news/cheap-jerseys-cheap-nfl-jerseys-free-7in838-wholesale-jerseys-from-china/ Society of America (PRSA). E Mail . Overused, Abused InvaluableLetters http://www.foolgags.com/ to the Editor Speak Directly to Your AudienceMarketing VS. Technology in Today MarketplaceOp Ed Articles Express Your Firm Point of ViewLet http://blogs.ktph.com.sg/nutrition/ Do Away With Press http://www.inmfrance.com/chmhorizon/?p=531 ReleasesCommunications
employees, Aaron Rodgers Jersey the investment community, the news media and key http://www.fusionmediaagency.com/blog/cheap-jerseys-cheap-nfl-jerseys-free-shipping-9fk84-wholesale-jerseys-from-china/ strategic alliances. He leaves Actavis with an unparalleled foundation from which we will continue to communicate our compelling story to all of our audiences around the world. I sincerely http://www.advcommunication.ro/cheap-jerseys-cheap-nike-jerseys-free-shipping-7sh62-wholesale-jerseys-from-china/ thank Charlie for http://treadingafineline.blogs.iva.co.uk/ his contributions and wish http://www.krossover.com/ him well as he focuses on his health." Mr. Mayr has served http://arquitecturaliviana.com/?p=492 as Chief Communications Officer of Actavis since April 2012. http://www.hjartumsgarden.se/2015/09/cheap-jerseys-mlb-jerseys-free-shipping-6rt25-wholesale-jerseys-from-china/ He joined Actavis (then Watson) as Senior Vice President, Corporate https://www.seniorpreneur.co.uk/?p=1704 Affairs in September 2009. Actavis plc (NYSE: ACT), headquartered in Dublin, Ireland, is a unique, global pharmaceutical company and a leader in a new industry model http://www.adaptconsultoria.com.br/sem-categoria/cheap-jerseys-cheap-jerseys-free-1rw856-wholesale-jerseys-from-china/ Growth Pharma. Actavis is focused on developing, manufacturing and commercializing innovative branded pharmaceuticals, high quality generic and over the counter medicines and biologic products for patients around the world. Actavis markets a portfolio of best in http://robbieboy.blogs.iva.co.uk/ class products http://www.verticalmeasures.com/ that provide valuable

Bellevue’s Government Organization Official City of Bellevue Website City Profile ProfileBusiness AssistanceInternational TradeDoing Business with the CitySister CitiesTaxes and Licenses NewsNext Generation BellevueAbout Streams, Lakes and WetlandsDrinking Water ConservationGreen BuildingNatural Lawn and GardenKeeping Waterways CleanCritical AreasSaving SalmonGarbage and Recycling ServicesVolunteeringCity HallEmergencies and Extreme Weather PreparednessCity AttorneyCity ClerkCity ManagerCivic Services Services (Permits) FinanceFireHuman ResourcesInformation TechnologyParks Community ServicesPlanning Community PoliceTransportationUtilitiesA city council fake cheap oakleys comprised of seven elected members governs Bellevue. The mayor and deputy mayor are both council members, chosen by the others to serve two year terms. The mayor cannot veto council decisions, but acts as both its chairperson and the city’s official host. Residents also have a voice in Bellevue’s replica oakleys store government through several volunteer boards and commissionsThe city manager is chief executive of the city, working under the direction of the council. Staff assigned to departments including Services, Parks Community Services, Utilities and Transportation, provide essential services to residents.
‘American Sniper’ called murder defendant ‘nuts’ Marine acted with forethought and malice when he fatally shot Chris Kyle, the former Navy SEAL whose best selling autobiography was turned fake oakleys Sunglasses into the hit movie "American Sniper," prosecutors told a Texas jury on Wednesday. sniper, as well as Kyle’s cheap ray ban outlet friend Chad Littlefield in February 2013 at a shooting range about 70 miles (110 km) southwest cheap oakleys outlet of Fort Worth. A jury of 10 women and two men is hearing the case in rural Erath County. Defense attorneys wholesale oakleys said Routh was insane at the time of the incident, suffering from post traumatic stress disorder caused by overseas deployments. They said when he killed them, Routh was in the fake cheap oakleys grip of a psychosis so severe that he did not know it was wrong. Routh was taken to the cheap replica ray ban range by Kyle, who had been helping fellow veterans heal the mental fake cheap oakleys scars stemming from combat. While cheap fake oakleys sales riding in the truck, Kyle sent a text message to Littlefield, who was sitting next to him in front, about Routh, sitting in back. The message read: "This

In a lot of my Lotto Blog posts and Articles that I have written, I expounded upon the virtues of using a reduced play list to enhance your odds of winning your Authenitc Mens Brad Smith jersey lottery jackpot. Although, this lottery approach applies in the same way well to all lotteries, one of the examples I used was the Lotto Texas 6/54 lottery.

In the example, I simply Authenitc Blue Chuck Bednarik jersey removed Elite Byron Maxwell jersey one lottery integer from play to establish the striking result Kids Byron Maxwell jersey this has on your chances of winning. As a result, the lottery player is left playing a new lottery called the Lotto Texas 6/53. This straightforward approach has the enormous consequence of removing nearly 3,000,000 wagers from play and a correspondent enhancement Elite Kids Byron Maxwell jersey in the Byron Maxwell jersey player’s chances

Infrequently, the lottery integer the player removes is one of the winning integers. Observably, in this case, the player wouldn’t have a chance of winning the lottery Authenitc Youth Brandon Graham jersey jackpot in that drawing. Although, that doesn’t happen very frequently. The player has 48 non winning numbers from which to choose. Consequently, he can easily make a Authenitc Kids Brandon Graham jersey superior choice over 90% of the time. With probability like these, it is rather baffling why everyone doesn’t apply this lottery approach . Nevertheless, there is the stipulation. Authenitc Blue Darren Sproles jersey Authenitc Womens Chuck Bednarik jersey Using this plan doesn’t mean you are going to win the lottery on Saturday, it just means you have increased your chances to jump for joy.

Watching lottery integer patterns Elite Kids Brad Smith jersey in the lottery’s history can help you expand a streak of good picks. What Elite Kids Brandon Graham jerseyAuthenitc Brandon Graham jersey Donnie Jones jersey studying the history of lottery digit performance.

For model, in the Lotto Texas, 6/54 lottery, the integer 45 has performed dreadfully badly over the lotteries history. In fact, it is the worst. It averages Authenitc Kids Chuck Bednarik jersey less Youth Byron Maxwell jersey than 1 hit every 15 drawings and it has extended dry spells of 36, 43, 29 and 31 drawings without a hit. In other words, it’s bad Elite Blue Brandon Graham jersey performance is not a fluke. It has been very poor over a prolonged period.

So, if this Authenitc Mens Brandon Graham jersey tendency continues, on the average, you would be able to improve your probability of Authenitc Blue Brad Smith jersey being right from 90% to 93.3%. Although, if you catch it on one of its extended vacations, you could ride this horse for 29 drawings or more, improving your chances of being right to 96.7% or better. So, the number 45 would be a fine candidate to do away with from your Play List. This is just a sampling, a taste; a hint of what serious lottery play is all about.

Other satisfactory choices for Lotto Texas 6/54 are integers 54 and 1. 54 has dry spells of 49 and 36 drawings. number 1 has dry spells of 38, 47 and 29 drawings.

So, can you constantly increase your chances of winning the lottery jackpot? Extremely! In fact, a genuine lottery player will be still more aggressive. Why? Because, he realizes that his probability of winning the lottery jackpot increase by removing more integers . He also understands that a more aggressive strategy will increase the integer drawings in which he will take away a winning integer from his play list. However, Authenitc Youth Chuck Bednarik jersey all things measured, putting some good lottery software in the hands of an experienced player, should allow him to achieve a success rate of 75% or better.

A math professor had worked out a formula that can increase your odds of winning to 47%. He has proven it by winning the lottery 5 TIMES.

the time, effort and resources expended to reach this Authenitc Gold Matt Moulson Elite Tyler Ennis Jersey Jersey Elite Blue Ryan Oreilly Jersey conclusion are incomprehensible to Authenitc Elite Blue Tyler Ennis Jersey Blue Zemgus Girgensons Jersey me. Authenitc White Tyler Ennis Jersey Knowing that there is no real recourse available, fighting the league and extending Elite White Evander Kane Jersey this debate would prove to be futile. We understand and Authenitc Gold Elite Blue Evander Kane Jersey Derek Roy Jersey greatly respect Women Evander Kane Jersey the responsibility of being one of 32 in this league and, on that basis, we will accept the findings of the report and take the appropriate actions based on those Authenitc Blue Derek Roy Jersey findings as well as any discipline levied by the league. In other words, "nothing’s going to happen to us, we still have our Super Elite Blue Tyler Ennis Jersey Bowl rings and Elite Ryan Oreilly Jersey all the money and accolades that come with it, so we don’t really care what you think. Oh, except that we think it’s Youth Tyler Ennis Jersey a disgrace that you spent any time and resources looking into this at all how dare you? Authenitc Gold Elite Blue Zemgus Girgensons Jersey Derek Roy Jersey We are Kid Zemgus Girgensons Jersey Elite Gold Tyler Ennis Jersey the Patriots!" Authenitc Gold Pierre Turgeon Jersey Kraft might as well have put out a statement saying "The Palace is Not Amused." In Authenitc Gold Ryan Oreilly Jersey some ways, Kraft is right, at least in terms of the reaction of the NFL. The league has often shown that integrity
The job of a physical therapist can be tough. While most people tend to brush off their importance by just calling them masseurs, the job is a lot more than that. Physical therapy is pretty much an all inclusive field which deals with all the physical ailments that a person may face. Pay Package Physical therapists generally charge on the hour or depending upon the number of sessions they take for an individual’s rehabilitation. So, based on the number of people coming in, and their individual rate, the starting salary is said to be around $50,000 $60,000. The salary also increases depending upon experience, and can go up to $80,000 per year. To put it in a nutshell, a physical therapist is the person to go to for any physical problems your body may be facing. Right from bone and muscular pain and muscle cramps to post surgery rehabilitation, the therapist has to do it all. He also has to employ an array of techniques to cure the people who come to him for treatment. To cure the patient,