Catholic Charities Fort Worth Transportation Services Form

Submit the completed form via email to transportation@ccfw.org, or fax it to (817) 123-4567. You can also submit the form online using the provided submission form link on the Catholic Charities Fort Worth website. Alternatively, you may mail the completed form to Catholic Charities Fort Worth, Transportation Services, 249 W. Thornhill Drive, Fort Worth, TX 76115. Ensure all required fields are completed, and the form is signed before submission. It is recommended to keep a copy of the submitted form for your records.

Make sure to submit your form before the scheduled transportation date. For 2024 and 2025, ensure all forms are submitted at least two weeks prior to the transportation service date to avoid any delays.

The purpose of this form is to collect necessary information from clients of Catholic Charities Fort Worth who need transportation services. It gathers personal details, contact information, emergency contacts, and destination information to ensure that transportation services are provided effectively. Submitting this form accurately and on time helps streamline the process and ensures clients receive the required support.

• 1. Client Name: The full name of the client requesting transportation services.
• 2. Home Address and Apt/Unit #: The full residential address of the client including apartment or unit number if applicable.
• 3. Apartment Complex Name: The name of the apartment complex where the client resides.
• 4. Primary Phone: The primary contact phone number of the client.
• 5. Date of Birth: The client's date of birth.
• 6. City and Zip Code: The city and zip code of the client's residence.
• 7. Secondary Phone: An alternate contact phone number for the client.
• 8. Emergency Contact Name and Number: Name and phone number of the person to contact in case of an emergency.
• 9. Ethnicity and Race: Ethnicity and race options to describe the client's background.
• 10. Gender: The gender of the client.
• 11. Number of People in Household: The total number of people in the client's household.
• 12. Total Annual Household Income: The total annual income of the client's household.
• 13. Destination Details: Details about the destination, including purpose, address, and city.
• 14. Client Signature and Date: Client's signature and the date of signing to certify the information provided.
• 15. Staff Signature and Date: Staff's signature and date verifying the completion of the form.
• 16. Written Notice of Beneficiary Rights Receipt: Indicates whether the client has received the written notice of beneficiary rights.

Failing to submit this form may result in the inability to access transportation services through Catholic Charities Fort Worth.

• Service Denial: Clients may be denied transportation services if the form is not submitted.
• Delayed Processing: Delays in processing requests for transportation services due to incomplete information.
• Inaccurate Records: Records may not be updated correctly without a submitted form.

• 1. New Service Requests: Submit this form when applying for new transportation services.
• 2. Updating Information: Use this form to update personal and contact information.
• 3. Emergency Contact Changes: Inform changes to emergency contact details using this form.
• 4. Trip Purpose Changes: Use this form to update the purpose and details of your trip.
• 5. Annual Verification: Resubmit the form annually to verify and update information on record.