New Client Application-Espanol

New Client Application-Espanol

Llene por completo esta solicitud. Si tiene preguntas o no entiende cualquiera de las preguntas en la solicitud por favor llame (205) 978-1000 (local) o 1-800-543-7143 y marque #1. Las solicitudes serán procesadas dentro de dos semanas de la fecha que nosotros las recibimos.

Solicitud para Servicio de Transporte
Por favor escribe en tinta oscura. Por favor llene toda la información en cada sección (el frente y el reverso).

Descarga PDF. .


Nombre
First Last

Fecha de nacimiento
/ /
MM               DD                YYYY

Sexo

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

Número de Seguro Social

Número de Medicaid

Número de teléfono (casa):
- -
(###)            ###              ####

Número de celular:
- -
(###)            ###              ####

Número de teléfono (trabajo):
- -
(###)            ###              ####

¿Podemos llamarle al trabajo?

¿Tiene un familiar que hable inglés?

Necesidades especiales:
Silla de ruedasEquipo médicoOtra

Información Estadística
Por la generosidad de nuestros donantes importantes, Kid One puede proveer servicio de transporte para las citas médicas que son necesarias. Muchas veces los donantes piden información estadística con el propósito de reportar y justificar el servicio.

La información que provee no va a determinar su elegibilidad y la información se va a mantener en confidencia.


Raza:

Tipo de cita:

Diagnosis

¿Está embarazada?

¿Fecha de parto?
/ /
MM               DD                YYYY
*Tiene derecho a una (1) cita posparto.

Nombre del Cliente (2)
La información que sigue refiere al cliente, el individuo que vamos a transportar.

Nombre
First Last

Fecha de nacimiento
/ /
MM               DD                YYYY

Sexo

Raza

Tipo de cita:

Diagnosis

¿Está embarazada?

¿Fecha de parto?
/ /
MM               DD                YYYY
*Tiene derecho a una (1) cita posparto.

Nombre del Cliente (3)
La información que sigue refiere al cliente, el individuo que vamos a transportar.

Nombre
First Last

Fecha de nacimiento
/ /
MM               DD                YYYY

Sexo

Raza

Número de Seguro Social

Número de Medicaid

Tipo de cita:

Diagnosis

¿Está embarazada?

¿Fecha de parto?
/ /
MM               DD                YYYY
*Tiene derecho a una (1) cita posparto.

Nombre de Padre/Tutor
First Last

Parentesco al Cliente:

Fecha de Nacimiento
/ /
MM               DD                YYYY

Necesidades especiales:
Silla de ruedasEquipo medicoOtra

Nombre del adulto responsable que va a acompañar el cliente a sus citas.
First Last

Parentesco al Cliente:

Fecha de Nacimiento:
/ /
MM               DD                YYYY

Necesidades especiales:
Silla de ruedaEquipo medicoOtra

Necesidad para Transporte
Aquí en Kid One estamos enfocados en cumplir nuestra misión con efectividad y eficiencia. Nuestro compromiso es proveer un servicio de calidad para familias en Alabama que no tienen medios de transporte para conseguir asistencia médica. Podemos proveer este servicio gracias al apoyo financiero de la comunidad local y nuestra meta es servir a personas con mayor necesidad. Además con este apoyo y compromiso adquirimos una responsabilidad con nuestros clientes, donantes, voluntarios, e integrantes de nuestro equipo.

¿Tiene acceso a transporte?

Si no, ¿por qué?
¿Cuales son otras opciones de transporte disponible en su área?

Información de Referencia

¿Cómo se enteró del servicio de Kid One?

Lo siguiente se refiere a la persona o agencia que le envió a Kid One.
First Last

Relación/Parentesco con el Cliente:

Nombre de Agencia

Número Teléfono:
- -
(###)            ###              ####

Número de Teléfono alternativo:
- -
(###)            ###              ####

Correo Electrónico:

Ingresos del Hogar
Si su hogar no tiene ingresos

Poder Legal Limitado
Yo, el firmante llamado “el cliente” he hecho, negociado, y por éste medio, hago constituyo, y nombro Kid One Transport (“Kid One”) como verdadero y Abogado, con plenos poderes de substitución para hacer, lo siguiente en mi nombre, lugar y en lugar de:
Recibir, tomar, endorsar, asignar, entregar y negociar cualquier cheque u otro papel comercial girado a mi mismo representando desenbolsos por servicios de transportación provistos por Kid One a mi favor y/o cualquier de mis niños y/o dependientes y por lo tanto ratifico y apruebo tales acciones
tomadas prioramente de Kid One. Entendido que ciertos bancos u otras instituciones financieras operan bajo éste poder legal limitado para depositar dicho cheques pagaderos a mi nombre, o a la cuenta de Kid One y por lo tanto absuelvo y sostengo a cualquier banco o institución financiero libre de cualquier reclamo o riesgo por depositando dicho cheques o papeles comerciales descritos aquí, los cuales sean presentados por Kid One para depositar en la cuenta de Kid One. Cualquier banco o institución financiero puede confiar en éste poder legal limitado hasta que sea notificado por escrito que el poder ha sido revocado.
Mi habilidad física o mental subsecuente a mi ejecución de éste poder legal limitado no revocara dicho poder el cual que dará vigente y en efecto no obstante habilidades físicas o mentales. Por lo tanto se extendere y sera obligatorio para los ejecutores, administradores, representantes legales, y
sucesores, respectivamente, por todas las partes.

Por lo tanto doy testimonio y firmo
/ /
MM               DD                YYYY

Nombre de la Persona que recibe el transporte en letra de imprenta (“Cliente”)
First Last

Firma de Cliente (Se require si es 19 años o mayor)
First Last

Descargos Generales
Tengo entendido que el Sistema de Transporte de “Kid One” es una agencia sin fines de lucro que provee transporte gratis para los lugares de salud o lugares que proveen asistencia de maternidad para las madres embarazadas y para los niños que por no tener transporte no pueden llegar a la facilidad o al lugar de salud que les provee la atención necesaria. En cambio por la transportación gratis que “Kid One” provee. Yo por parte mía , de mis herederos, ejecutores, administradores, y asignados como padre o tutor del niño inscrito abajo, por este medio (1) asumo responsabilidad total por utilizar los servicios de transporte que “Kid One” provee, y (2) exonero, absuelvo, para siempre perdono, descargo y mantengo inocentes a “Kid One”, sus sucesores y asignados, empleados y agentes y cada uno de sus herederos, ejecutores y administradores, y a todas otras personas, firmas y corporaciones, de cualquier reclamo, demanda, derechos y causa de acción, de cualquier tipo o índole, en la ley o equidad, que tenga conección o se desarrolle con debido a la transportación que “Kid One” provee para mí y/o para mi niño.
Por medio de mi firma abajo, Yo reconozco: (1) que tengo diecinueve (l9) años o más, (2) que soy el padre o tutor del niño identificado abajo, (3) que yo tengo la autoridad de entrar en este acuerdo por parte mía y del niño identificado abajo, y (4) que yo he leído con cuidado y entiendo por completo este Descargo y reconozco los términos aquí expuestos, y firmo esto como un acto voluntario. El incumplimiento de las normas y regulaciones impuestas por “Kid One” resultará en la terminación del servicio. Integrantes del equipo de “Kid One” tienen el derecho de negar el servicio de transporte en cualquier momento y por cualquiera razón. Kid One Transport no es responsable de los bienes personales de los clientes que se queden en el vehículo de transporte.

Firma del Padre/ Tutor
First Last

Fecha
/ /
MM               DD                YYYY

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