'N' RIDE APPLICATION
Call ‘N’ Ride is a transportation assistance program that will transport eligible residents of Montgomery County to appointments within the Montgomery County local service area*. Applicants must be age 67 and above, or persons age 16 and above with mental or physical disabilities.
To apply for this program, please complete and print this confidential application and return it along with all required documentation to the address below:
CALL ‘N’ RIDEP. O. BOX 8465GAITHERSBURG, MD. 20898-8465TELEPHONE: 301-948-5409 FAX: 301-258-0206
* Please see guidelines for specific parameters of program
THE FOLLOWING QUESTIONS ARE
ASKED TO DETERMINE YOUR PROGRAM ELIGIBILITY.
1. RESIDENCY AND AGE:
Is this a group home, nursing home,
2A. Do you currently receive SSI (Supplemental Security Income), GPA (General Public Assistance), or Food Stamps? Yes
If you answered YES to 2A., please submit a letter of proof from the agency from which you receive assistance. Skip to Question #3. If you answered NO, please complete the following section.
2B. If you do not
receive SSI, GPA, or Food Stamps, what is your gross monthly income from all sources? $
Please send proof.
If answered yes, please explain
your disability is temporary, how long do you anticipate being disabled?
you require the use of
4. PLEASE CHECK ONE OF THE FOLLOWING:
The participant will directly order and handle coupons themselves.
The following person will order and handle coupons and should be contacted
if there are any questions regarding the participant’s use of the service.
5. THE FOLLOWING QUESTIONS PROVIDE
STATISTICAL INFORMATION FOR PROGRAM EVALUATION. PLEASE ANSWER THESE QUESTIONS:
5A. Are you able to utilize:
Ride-On Bus? Yes
5B. Are you aware you can ride free on Ride On and Metrobuses all day everyday? Yes
5C. If not, how do these services not meet your needs?
6. HOW MANY TIMES PER MONTH
DO YOU REQUIRE TRANSPORTATION?
6A. Do you currently receive transportation services from any agency or service provider? (i.e.
City of Rockville, Jewish Council for Aging, Spanish-Speaking Community of Maryland, Special Transportation, Metro Access, etc.)
6B. If yes, please specify:
The information provided by me
is confidential, and is used only to determine my eligibility to participate
in the Call 'N' Ride Program. I certify that all information contained on
this form is true and correct