City Of Oakland Senior Companion Program Client Application Form
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1
2Senior Companions
Taxi Up & Go Project
Department of Human Services
Senior Companion Program
150 Frank H. Ogawa Plaza, Suite 4340
Oakland, CA 94612
CLIENT APPLICATION FORM
I am applying for:
I am applying for:
I am applying for:
I am applying for:
Taxi Up & Go (TUGO) Transportation for medical or groceries
A Senior Companion Volunteer to visit me once a week
Client Name:
Client Name:
Client Name:
Client Name: Mr/Mrs/Ms
Mr/Mrs/Ms
Mr/Mrs/Ms
Mr/Mrs/Ms
Last Name
Last Name
Last Name
Last Name
First Name
First Name
First Name
First Name
Middle Initial
Middle Initial
Middle Initial
Middle Initial
Gender
Gender
Gender
Gender: : : :
Male
Male
Male
Male
Female
Female
Female
Female
Date of Birth
Date of Birth
Date of Birth
Date of Birth
/
/
/
/
/
/
/
/
Home Address
Home Address
District #:
District #:
Home Address
Home Address
District #:
District #:
City
City
City
City
Zip Code
Zip Code
Zip Code
Zip Code
Home Telephone
Home Telephone
Home Telephone
Home Telephone
( ( ( (
) ) ) )
Mobile Telephone
Mobile Telephone
Mobile Telephone
Mobile Telephone
( ( ( (
) ) ) )
Ethnicity
Ethnicity
Ethnicity
Ethnicity
Do you
Do you
Do you
Do you speak English?
speak English?
speak English?
speak English?
Yes
Yes
Yes
Yes
No
No
No
No
If No, what is your primary language?
If No, what is your primary language?
If No, what is your primary language?
If No, what is your primary language?
Do you receive care from
Do you receive care from a Caregiver or an IHSS Provider? (Please provide their name below.)
a Caregiver or an IHSS Provider? (Please provide their name below.)
Do you receive care from
Do you receive care from
a Caregiver or an IHSS Provider? (Please provide their name below.)
a Caregiver or an IHSS Provider? (Please provide their name below.)
Caregiver/IHSS Provider
Caregiver/IHSS Provider
Caregiver/IHSS Provider
Caregiver/IHSS Provider
Relationship
Relationship
Relationship
Relationship
Telephone Number
Telephone Number(s)
Telephone Number
Telephone Number
(s)
(s)
(s)
Monthly Income Amount $
Monthly Income Amount $
Monthly Income Amount $
Monthly Income Amount $
(Check all that apply)
(Check all that apply)
(Check all that apply)
(Check all that apply)
SSI
SSDI
Retirement
Veteran's
Medicare
Medi-Cal
Other (please specify)
Mobility & Assistance
Mobility & Assistance
Mobility & Assistance
Mobility & Assistance
Ambulatory (able to walk)
Power Wheelchair
Scooter
Service Animal
Manual Wheelchair
Walker
Cane
White Cane
Other
(please specify)
Do you have difficulty performing any of the following tasks?
Do you have difficulty performing any of the following tasks?
Do you have difficulty performing any of the following tasks?
Do you have difficulty performing any of the following tasks?
Stand
Lift/Carry
Bend
Reach
Grasp
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