2. 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).

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:

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

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: [email protected] OR MAIL / HAND DELIVER to: Hanover Department of Community Resources 12310 Washington Highway, Ashland, VA 23005.
54. Address Verification
55. Verification of Age or Disability
57. Other
59. 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
61. 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.

    1. Medicaid Acknowledgement
63. 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 

    1. Notify me by telephone in addition to U.S. mail
    2. Notify me by electronic mail in addition to U.S. mail
65. 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.

Leave This Blank:


67. 1. Receive an email copy of this form.
68. Email address

    This field is not part of the form submission.

69. Submit

* indicates a required field