Senior Transportation Services Registration - Township of SchaumburgTownship of Schaumburg Senior Transportation Services Registration - Township of Schaumburg

Senior Transportation Services Registration

This form is for Senior Adults, aged 55 and older, wishing to request transportation by Schaumburg Township.

If you are a Disabled Adult, over the age of 18, wising to request transportation by Schaumburg Township, please visit our Transportation page and fill out the Disabled Adults Transportation Services Registration Form.
MM slash DD slash YYYY
Your Name(Required)
Your Name
Your Email Address(Required)
Your Email Address
Your Address(Required)
Your Address
MM slash DD slash YYYY
Spouse Name
Spouse Name
Photo Permission for Schaumburg Township Purposes (required)(Required)
Photo Permission for Schaumburg Township Purposes (REQUIRED)
Gender(Required)
Gender
Ethnicity(Required)
Ethnicity

If you have a primary language other than English, please specify that language below. If English is your primary language, please type N/A.
Type of Housing(Required)
Type of Housing

If you live alone, please enter 1.
Lift Required(Required)
Lift Required
Aide Required(Required)
Aide Required
Below Poverty(Required)
Below Poverty
Emergency Contact Name(Required)
Emergency Contact Name - Emergency contact should be someone outside of your household.