Client Application

I CARE, Inc.
735 Sycamore Drive, Decatur, GA 30030
Office: 404.377.2273
Client Application Form

Date

Last Name

First Name

Date of Birth

Street Address

City

Zip

Phone number (home)

(cell)

E-mail address

Where did you hear about I CARE?

Emergency contact name

Phone

Please provide the name and phone number of one reference (someone not related to you)

Name

Phone

Do you use the assistance of any of the following?

Cane

Walker

Wheelchair
(We can only accommodate foldable wheelchairs)

Are you eligible for MEDICAID?

Are you eligible for Para Transit (MARTA Mobility)?

What is your reason for applying for I CARE service?

Ethnicity (Optional)

Please acknowledge receipt of this document and the attached guidelines, with your signature
and date below

Signature

Clear

Date

Thank you! Upon completing the application, please mail it in to I CARE, Inc. 735 Sycamore
Drive, Decatur GA 30030, email back to coordinator@icareseniors.org, or call I CARE at
404-377-2273 to schedule a sign-up appointment.

If you are human, leave this field blank.

Client Application

Company

Links

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