Vouch For Me Program – MAX Transit – Birmingham Jefferson County Transit Authority

Demographic Consent Form(Paratransit Only)

Vouch for Me is a FREE community-based program providing non-emergency medical transportation services to and from medical appointments, grocery stores, and pharmacies to individuals in the Birmingham area. Please complete this application for assistance. A team member will contact you following the review with additional information.

You can submit this application online at maxtransit.org or by using one of the following options:

Email: ada@bjcta.org

Mailing Address: 1801 Morris Ave. Birmingham Al. 35203 (Attention: ADA Office)

Drop-Off:

• Central Station: 1700 Morris Ave. Birmingham, Al. 35203

• Woodlawn Transit: 4802 Ave. W. Birmingham, Al. 35208

• Crossplex Transit Center– 5613 1st Ave. N. Birmingham Al. 35212

For questions or information: Customer Care Center: (205) 521-0101

Personal Information

First Name

Last Name

Current Address: Street, Apartment, City, State, Zip*

Current Address: Street, Apartment, City, State, Zip

Primary Phone*

Primary Phone

Is this a mobile number? *

Yes

Date of Birth (mm/dd/yyyy)*

Select Date of Birth ×

Limit one round trip

Special Accommodations

Certification

I certify that the information I have provided in this application is true and correct. I understand that falsification of information may result in denial of service. I further understand that all information required herein will be considered confidential and will be used only by The Birmingham-Jefferson County Transit Authority and Daniel Payne Legacy Village Foundation to determine eligibility for transportation services.

I have read and understand the project description material provided.

I voluntarily agree to participate in the project.

I understand the procedures of confidentiality (e.g., anonymization, pseudonyms, etc.).

I understand the purpose use of data in research, publication, sharing, and archiving.

I understand that other researchers will have access to all or some data upon agreement to preserve the terms and confidentiality specified in this form.

Name (First and Last)

Signature

Date*

Date ×

Special Accommodations

Signature

Case/Social Worker Signature

Your form has been submitted

Quick Links

BJCTA Administrative Offices

1801 Morris Avenue, Birmingham AL 35203

+1 (205) 521-0101

Click Map for Directions

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