ELIGIBILITY:
This program is currently available for Homebound Individuals.
• This includes seniors aged 65+ who are unable to leave home for medical reasons OR a person with a disability (regardless of age) who requires in-home assistance.
• To be eligible for this program, you must meet one of the following criteria:
-A senior 65+ unable to leave home for medical reasons
-A person with a disability who requires in-home assistance
-Require use of adaptive equipment (like a ventilator, crutches, a walker, a wheelchair, etc.) and/or accessible transportation to leave home
-Leaving home is not an option for you because doing so requires considerable and taxing effort

-Caregivers of homebound individuals are eligible for vaccination during the same appointment (Up to 3 people per household)

IMPORTANT NOTES:
• Please schedule only one appointment per household.
• If multiple people are expected at one appointment, choose ONE of the patients to be registered using this form. All other patients will be registered separately at the time of the appointment.
•Please use your full legal name when registering to ensure accurate patient records.
• No government issued ID is required. Insurance will be requested. However, uninsured persons will be served free of charge. Anyone under 18 must have a parent or guardian with them to sign consent.

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At Home - West Region (Evening)

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