Ready Ride Supportive Services Application

I understand that the information I am providing on this form is for registration purposes. The information will be used by the U.S. Health and Human Services Administration for Community Living (ACL), the Minnesota Board on Aging (MBA) and the local Area Agency on Aging to create statistical reports. ACL, MBA, or its assignees may use this information to conduct a study and/or survey of this service. In addition, information provided here, may be used by other service providers to help identify other services from which I may benefit. This information will not be released to anyone other than the above mentioned parties in a way that will identify me as an individual unless I sign a separate consent for that purpose.
My signature (written or typed) indicates my agreement for this information to be used as indicated above.

Upon submitting this Ready Ride form, you will be prompted to complete the Live Well at Home Rapid Screen Form. Please do not skip this form as completion of both forms is required for determining the services WCMCA has available for you. Thank you!