New Client Application – English

Name

Date of Birth

/ /

Gender

MaleFemale

Address

United StatesCanadaAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatia (Hrvatska)CubaCyprusCzech RepublicCzechoslovakia (former)DenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGMGambiaGeorgiaDEGermanyGhanaGIGibraltarGreat Britain (UK)GreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea (North)Korea (South)KuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNeutral ZoneNew CaledoniaNew Zealand (Aotearoa)NicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaGeorgia and S. Sandwich Isls.Saint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSeychellesSierra LeoneSingaporeSlovak RepublicSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSt. HelenaSt. Pierre and MiquelonSudanSurinameSvalbard and Jan Mayen IslandsSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUSSR (former)UgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican City State (Holy See)VenezuelaViet NamVirgin Islands (British)Virgin Islands (U.S.)Wallis and Futuna IslandsWestern SaharaYemenYugoslaviaZaireZambiaZimbabwe

Social Security #

Medicaid #

Home Phone

- -

Cell Phone

- -

Work Phone

- -

May we call you at work

YesNo

Do you or a family member speak English

YesNo

Special Needs:

WheelchairMedical EquipmentOther

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

BlackWhiteHispanicAsianOther

Type of Appointment

MedicalMental HealthDentalEye CarePrenatalPostnatalTherapyOther

Diagnosis

What type of insurance do you have?

MedicaidAll KidsPrivate Insurance CarrierNo Insurance

Are you a prenatal patient

YesNo

If so, what is your due date?

/ /

Name of Client (2)

The following information pertains to the client, the individual receiving the transport

Name

Date of Birth

/ /

Gender

MaleFemale

Race

BlackWhiteHispanicAsianOther

Social Security #

Medicaid #

Special Needs:

WheelchairMedical EquipmentOther

Type of Appointment

MedicalMental HealthDentalEye CarePrenatalPostnatalTherapyOther

Diagnosis

What type of insurance do you have?

MedicaidAll KidsPrivate Insurance CarrierNo Insurance

Are you a prenatal patient

YesNo

If so, what is your due date?

/ /

Name of Client (3)

The following information pertains to the client, the individual receiving the transport

Name

Date of Birth

/ /

Gender

MaleFemale

Race

BlackWhiteHispanicAsianOther

Social Security #

Medicaid #

Special Needs:

WheelchairMedical EquipmentOther

Type of Appointment

MedicalMental HealthDentalEye CarePrenatalPostnatalTherapyOther

Diagnosis

What type of insurance do you have?

MedicaidAll KidsPrivate Insurance CarrierNo Insurance

Are you a prenatal patient

YesNo

If so, what is your due date?

/ /

Name of Parent/Legal Guardian

Relationship to client

Date of Birth

/ /

Special Needs:

WheelchairMedical EquipmentOther

Name of responsible adult accompanying the client to appointments

Relationship to client

Date of Birth

/ /

Special Needs:

WheelchairMedical EquipmentOther

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

YesNo

If not, why?

Referral Information

How did you learn about Kid One Transport services?

Social WorkerDoctor's OfficeTVNewspaperMagazineFriend/RelativeKid One BrochuresKid One websiteOther

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

Relationship to client

Agency Name

Phone Number

- -

Alternate Phone Number

- -

Email

Household Income

$0$0-$10,000$10,001-$20,000$20,001-$30,000$30,001-$40,000$40,001-$50,000$50,001-and above

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

/ /

Printed Name of Person Receiving Transport (Client)

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

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/Legal Guardian

Date

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