My Freedom Transportation Application

I understand the purpose of this form is to determine if I am eligible to participate in the My Freedom program offered through CICOA Aging & In-Home Solutions. I understand this program is designed to serve individuals 60 or older, or of any age with a disability who have difficulty using regular public transportation due to their disability.
I certify the information I have provided on this intake form is true and accurate to the best of my ability.
I agree any transportation fare purchased is my for my personal use only. I agree not to give or sell my fare to another individual. I acknowledge that giving or selling my fare to other individuals may prevent continued participation in the My Freedom program.