New Client Application – English

Client # 1 Information. This section pertains to the first client receiving transportation.

Name(Required)

First Last

Date of Birth(Required)

Gender

Address(Required)

Street Address Address Line 2 City State ZIP Code

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

Type of Appointment:

Medical

Mental Health

Dental

Eye Care

Prenatal

Postnatal

Other

Diagnosis

What type of insurance do you have?

Are you a prenatal patient?

If so, what is your due date?

*Prenatal clients are eligible for service up to 1 year postpartum.

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 (select all that apply)

Black

White

Hispanic

Asian

Other

Parent/Guardian Information. This section pertains to the parent/guardian of the client who is receiving the transportation.

Name of Parent/Guardian

First Last

Relationship to the Client:

Date of Birth

Special Needs:

Wheelchair

Medical Equipment

Other

Name of the responsible adult accompanying the client to appointments:

First Last

Relationship to the Client:

Date of Birth

Special Needs:

Wheelchair

Medical Equipment

Other

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 no, why not?

What other options for transportation are available in your area (e.g. buses, taxis, friend’s vehicle, etc.)?

What is your household income?(Required)

Referral Information. This section pertains to how you have heard about Kid One Transportation.

How did you learn about Kid One Transport services?

Social Worker

Doctor's Office

TV

Newspaper

Magazine

Friend or Relative

Kid One Brochures

Kid One Website

Other

Referring Party. If you are a referring party, please complete the section below.

Your Name

First Last

Relationship to the client:

Agency Name

Phone Number

Alternate Phone Number

Email

Enter Email Confirm Email

Release Forms. Please read this section carefully and provide your eSignature if you agree to the terms and conditions.

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(Required)

Printed Name of Person Receiving Transport (Client)(Required)

First Last

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

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. In the event that I or someone that I am responsible for uses or requires certain specialized equipment, such as a car seat, wheelchair, breathing device, or any other such medical or assisting device, I acknowledge and represent that I will be fully and exclusively responsible for ensuring that such equipment is properly secured in such a fashion to provide normal operation and safe transportation. In the event that such equipment is not properly secured, I will take all steps necessary to notify a Kid One Team Member prior to beginning any trip so that the equipment can be properly secured and operated prior to resuming the trip. 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/Guardian(Required)

First Last

Today's Date(Required)

New Client Application – English

New Client Application - English