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Hanover DASH Registration Form
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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).
Last Name
First Name
Address
City
State
-- Select One --
VA
Zip Code
Date of Birth
Date of Birth
Gender
-- Select One --
M
F
Phone Number
Email Address
Race
-- Select One --
White
Black or African American
American Indian or Alaskan Native
Chinese
Filipino
Asian Indian
Other Asian
Vietnamese
Korean
Japanese
Other
Race - Other
Veteran
Yes
No
How did you hear about the program?
Proof of Qualifications:
Please check the appropriate box and attach the documents required in both Section A AND Section B.
Section A
Proof of Hanover County Address listed above. Check one of the following and include a copy of it with this form.
Copy of a utility bill
Copy of your Voter Card
Copy of lease or other official document with your name and address
Section B
Proof of Qualification - Check one qualification and include a copy of one of the required documents with this form
Aged 60 or older:
Copy of your valid Virginia driver’s license or Virginia issued photo ID
Photocopy of your birth certificate
Disabled:
Copy of a doctor’s letter.
Social Security statement
Medicare card (Red, White and Blue Card)
Mobility Aides-Do you use any of the following when traveling in a vehicle:
-- Select One --
Wheelchair
Scooter
Hoveround
Walker
Other
None
Other
Emergency Contact Information
Last Name
First Name
Address
City
State
Zip Code
Phone Number
Email Address
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.
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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.
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