Nurses & Neighbors* Non-Emergency Medical Transportation Application

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Thank you for your interest in our 25 for 80 non-emergency medical transportation (NEMT) project.

To participate, here are the steps:

1. Read our frequently asked questions (FAQ) on our web site: delawareinstitute.org.
2. Complete this online form (paper form available – contact us).
3. Approval/Denial will be emailed to you.
4. Once you are approved, you can schedule a ride by calling 302-582-0072.
5. A ride voucher valued at $100 will be automatically credited to your account once you are approved. Preferences are given to underserved and veteran groups. Ride voucher is only valid for rides scheduled through our virtual on-demand ride board with our care coordinator.

This project is funded in part by a grant from AARP. Rolling enrollment and ride vouchers are available while funding lasts. Sussex County residents age 70+ are eligible to apply for this program. Please visit our web site at delawareinstitute.org for updates.

We do not distribute your contact information. When you complete this form, you are allowing Nurses & Neighbors to contact you.

Nurses & Neighbors Collaborative. We are a 501C (3) non-profit with the mission of improving health and wellness of our neighborhoods through nurse-led projects.

Name *

Address *

Phone number (please note mobile or landline) *

Email *

Your age (We will ask for your date of birth when we schedule your ride). *

80+

70+

none of the above

Are you a resident of Sussex County, DE? *

yes

Are you a U.S. military veteran? *

Yes

Trusted Contact's Name

Trusted Contact's Phone Number (note cell or landline)

Are you affiliated with the following Community Organizations (check all that applies)

BayHealth Cancer Institute

Cape Henlopen Senior Center

Cheers Senior Center

Community Resource Center

Delaware Cancer Network

Delaware Hospice

Lewes Senior Center

La Red Health Center

Nurses & Neighbors (resident of a neighborhood)

Shepherd's Office

Village Volunteers

None of the above

Other:

Comments (such as special needs)

Please read our 25 for 80 FAQ before signing for the application. *

I have read and agree with Nurses & Neighbor's 25 for 80 NEMT Program and terms.

Required

Enter your name to represent your signature and confirming that you are applying for the Nurses & Neighbors' 25 for 80 NEMT program.
*

Date of signature
*

YYYY

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