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Wayne County Transportation Eligibility Form

Wayne County

Transportation Program Eligibility Form

If you prefer to print your eligibility form to be emailed or faxed, please download and fill out the application below. If you don't have any income documentation, please also fill out the income self-declaration form and send that in as well. Return them and copies of any required documentation to Community Action Wayne/Medina fax (330.264.9948), email (transportation@cawm.org) or mail to Transportation at Community Action Wayne/Medina at 905 Pittsburgh Ave, Wooster, OH 44691. All of your information is confidential and will not be shared without your permission.

Online Eligibility Form - Wayne County Transportation
What category of transportation assistance are you looking for? Check all that apply
For example, I need transportation for going... to and from work Monday through Friday 8 a.m. to 5 p.m. at 123 Main Street in Shreve or to multiple doctors {list when and where} or monthly grocery shopping.
First Name *
Last Name *
Country
Address Line 1 *
Address Line 2
City *
State/Province *
Postal Code *
Month
/
Day
/
Year
Gender
Ethnicity
Disabled
Any Mobility devices
Any personal care assistant who may ride with you?
Veteran
Education
Health Insurance
Family Type
Food Stamps
If applicable
Cash Assistance
If applicable
Housing
Rental Assistance
If applicable
Client Income
Sources of Income
Landlord Information
First Name
Last Name
Country
Address Line 1
Address Line 2
City
State/Province
Postal Code
Other Household Members
For each house hold member, please include: SSN#, Last Name, First Name, Date of Birth, Gender, Disabled, Ethnicity, Education, Health Insurance, Veteran
Other Household Income
First Name
Last Name
Household Member 1 - Income
Household Member 1 - Sources of Income
First Name
Last Name
Household Member 2 - Income
Household Member 2 - Sources of Income
Total Household Income
Do you have access to a safe, working vehicle and the ability to transport yourself?
Do you have anyone that would be able to transport you, with or without gas assistance?
We use various methods such as calls, texts, and emails to stay in touch with clients regarding local transportation programs, enrollment processing, scheduling updates, and more. If you prefer not to receive these communications, please indicate by checking the relevant box below:
I CERTIFY THAT THIS STATEMENT IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE, AND AUTHORIZE THE RELEASE OF ANY OR ALL INFORMATION NECESSARY FOR VERIFICATION PURPOSES
Month
/
Day
/
Year

If you currently have no income documentation, please fill out an additional form:

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