Street Address*
City*
State* Choose one... Alabama Alaska American Samoa Arizona Arkansas Armed Forces America Armed Forces Europe Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas United States Minor Outlying Islands Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming
Zip Code*
Primary Phone*
Secondary Phone
Email Address*
Date of Birth*
Monthly Income* <$900 $901-$1,800 $1,801-$2,500 >$2,500
List the name of one person or agency that we may contact in the case of an emergency:
First Name*
Last Name*
Middle Initial*
Address*
City*
State*
Zip Code*
Email*
Home Phone
Cell Phone*
Do you use any assistive devices?
If yes, please describe:
If using a wheel chair, please note if it is powered or manual?
If you use a wheel chair, please note if it is powered or manual?*
If you use a wheelchair, would you prefer/need to use the device while riding the PIC bus?
If you use a wheelchair, prefer/need to use device?* Yes No Three
Will you regularly need driver assistance to/from the bus?
If yes, please describe
I certify that all the information on this registration form is true and correct. I understand that I am responsible for having a copy of the required State identification for verification of eligibility with this application. Enter your full name below to represent your signature. Full Name (Applicant Signature)*
Date*
If someone other than the applicant or the applicant's guardian is preparing this form, please provide the following information about the preparer: Preparer/Guardian First Name
Preparer/Guardian Last Name
Preparer/Guardian Middle Initial
Relation to Applicant
Preparer/ Guardian Phone Number
Preparer/Guardian Full Name (Signature)
Date (Preparer/Guardian)*
I would like to receive information from Partners In Care Maryland, Inc.
