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Hanover DASH Registration Form

  1. Hanover DASH Registration Form

    Applicants must be Hanover County residents and provide proof that they are aged 65 or older, or have a disability. Acceptable documentation is listed below. Information provided is for agency use only. To apply, complete this form and attach proof of residency and qualifications. For help to complete or questions, call 804-365-DASH (3274).

  2. Veteran
  3. Proof of Qualifications:

    Please check one box in Section A, and one box in Section B, and attach a copy of the documents required.

  4. Section A
    Proof of Hanover County Address listed above. Check one of the following and include a copy of it with this form.
  5. Section B
    Proof of Qualification - Check one qualification and include a copy of one of the required documents with this form
  6. Emergency Contact Information
  7. Please upload qualifying documents. OTHER OPTIONS FOR SUBMITTING DOCUMENTS: FAX to 804-365-4299; EMAIL: [email protected] OR MAIL / HAND DELIVER to: Hanover Department of Community Resources 12310 Washington Highway, Ashland, VA 23005.
  8. Consent to Share Information*

    By checking this box I consent to have my contact information shared with approved transportation providers.

  9. Medicaid Acknowledgement (for Medicaid recipients only) *

    By checking the box below, I confirm that I have exhausted all transportation resources offered by my Medicaid MCO.

  10. Response Request (Optional)

    Once application is received, a response will be sent by U.S. mail within 7 days.

    If you would like a response in addition to U.S. mail, please indicate your preference 

  11. Notice

    Hanover County is committed to ensuring that no person is excluded from participation in, or denied the benefits of its transit services on the basis of race, color or national origin, as protected by Title VI of the Civil Rights Act of 1964. For additional information on Hanover County’s nondiscrimination policies and procedures, or to file a complaint, please visit the website at www.HanoverDASH or contact Debra Preston, PO Box 470 Hanover, VA 23069.

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  13. This field is not part of the form submission.