Hanover DASH Registration Form

2. Hanover DASH Registration Form
   Applicants must be Hanover County residents and provide proof that they are aged 60 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).

   Applicants must be Hanover County residents and provide proof that they are aged 60 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).

4. Last Name

5. First Name

7. Address

8. City

9. State
   -- Select One --VA

10. Zip Code

12. Date of Birth
    Date of Birth

13. Gender
    -- Select One --MF

14. Phone Number

16. Email Address

17. Race
    -- Select One --WhiteBlack or African AmericanAmerican Indian or Alaskan NativeChineseFilipinoAsian IndianOther AsianVietnameseKoreanJapaneseOther

19. Race - Other

21. Veteran

    1. Yes
    2. No

22. How did you hear about the program?

24. Proof of Qualifications:
    <b>Please check the appropriate box and attach the documents required in both Section A AND Section B. </b>

    Please check the appropriate box and attach the documents required in both Section A AND Section B.

26. Section A

    Proof of Hanover County Address listed above. Check one of the following and include a copy of it with this form.

    1. Copy of a utility bill
    2. Copy of your Voter Card
    3. Copy of lease or other official document with your name and address
28. Section B

    Proof of Qualification - Check one qualification and include a copy of one of the required documents with this form

    1. Aged 60 or older:
       • Copy of your valid Virginia driver’s license or Virginia issued photo ID
       • Photocopy of your birth certificate
    2. Disabled:
       • Copy of a doctor’s letter.
       • Social Security statement
       • Medicare card (Red, White and Blue Card)
30. Mobility Aides-Do you use any of the following when traveling in a vehicle:
    -- Select One --WheelchairScooterHoveroundWalkerOtherNone

32. Other

36. Emergency Contact Information

38. Last Name

39. First Name

41. Address

43. City

44. State

45. Zip Code

47. Phone Number

48. Email Address

52. Please upload qualifying documents. OTHER OPTIONS FOR SUBMITTING DOCUMENTS: FAX to 804-365-4299; EMAIL: HanoverDASH@Hanovercounty.gov OR MAIL / HAND DELIVER to: Hanover Department of Community Resources 12310 Washington Highway, Ashland, VA 23005.

    Please upload qualifying documents. OTHER OPTIONS FOR SUBMITTING DOCUMENTS: FAX to 804-365-4299; EMAIL: HanoverDASH@Hanovercounty.gov OR MAIL / HAND DELIVER to: Hanover Department of Community Resources 12310 Washington Highway, Ashland, VA 23005.

54. Upload

55. Upload 2

57. Upload 3

58. Upload 4

60. Consent to Share Information*

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

    1. Consent to share information
62. 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 Lisa Adkins, PO Box 470 Hanover, VA 23069.

    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 Lisa Adkins, PO Box 470 Hanover, VA 23069.

Leave This Blank:


64. 1. Receive an email copy of this form.
65. Email address

    This field is not part of the form submission.

66. Submit

* indicates a required field