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Bay Village Senior Transportation Waiver

  1. BAY VILLAGE SENIOR TRANSPORTATION APPLICATION

  2. Medical Information

  3. Emergency Contact Information

  4. Will you require accommodation for a wheel chair?

  5. Will you require an escort for medical/other appointments?

  6. Passengers must provide own escort if needed. The City of Bay Village reserves the right to request passenger have an escort.

  7. By your signature you indicate that you are accepting these services in good faith and release the City of Bay Village and its agents and the Community Services Department and its representatives from liability or for any injury, accident, theft, loss or damage to property which may occur. I have read and/or understand the Bay Village Community Services Department Transportation Procedures.

  8. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

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  10. This field is not part of the form submission.