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2. This online application should only be filled out by a referring social worker from approved dialysis locations. Upon receiving and evaluating the application, a Department of Transportation Services (DTS) staff member will reach out by telephone and/or email advising the social worker of the status of the application. The potential consumer of our services should be advised by the social worker of the following: As of December 31, 2013, Gloucester County no longer provides dialysis transportation on holidays or weekends. Gloucester County only transports to a dialysis center closest to the consumers' residence. Once a time slot, days, and the location is approved, any subsequent changes in the aforementioned criteria of your original application may result in Gloucester County being unable to meet the new requirements due to previous commitments. In this case, you may be placed on a waiting list until such time availability arises on a route. You would also be responsible for your own transportation to and from the dialysis unit during this period. The completion of this application does not guarantee approval or utilization of Gloucester County Transportation services. When services cannot immediately be rendered, the consumer will be placed on a waiting list. When availability arises for you, we will contact you to verify you still desire transportation. You are invited to contact us at any time to check your status on the waiting list. Please call 856-686-8350 with any questions regarding this process.
4. Name of Applicant*
5. Email Address
7. Address*
9. City*
10. State*
11. Zip Code*
13. Phone Number*
14. Emergency Phone Number
16. Emergency Contact Person*
17. Date of Birth*
    Date of Birth
18. Last 4 Digits of SS#*
20. Racial or Ethnic Group*
    -- Select One --American Indian / AlaskanAsian / Pacific IslanderBlack / African AmericanHispanic / LatinoWhite / Caucasian
22. Gender*

    1. Female
    2. Male
24. Mobility Aids*
    -- Select One --CraneCrutchesElectric WheelchairManual WheelchairMotorized ScooterWalkerNone
26. Type of Disability*

    1. Cognitive
    2. Hearing
    3. Mental
    4. Mobility
    5. Oxygen Tank
    6. Service Animal
    7. Vision
    8. None
27. Please select location of program*

    1. Fresenius Swedesboro
    2. Fresenius Woodbury
    3. Kennedy Sewell
    4. Renal Davita Sewell/Mantua
29. Please select each day that you will need transportation. Please be advised that there is not transportation provided on Saturday, Sunday, or Holidays.*

    1. Monday
    2. Tuesday
    3. Wednesday
    4. Thursday
    5. Friday
    6. One-Way
    7. Round-Trip
31. Appointment Chair Time*
32. Anticipated Length of Appointment (example 1.0 hour)*
34. Referring Agency or Person
36. Do you currently use New Jersey Access Link Services to get to work, school, or training?*

    1. Yes
    2. No
37. If you answered No to previous question, have you ever applied for New Jersey Access Link Services?*

    1. Yes
    2. No
38. Have you ever been denied New Jersey Access Link Services?*

    1. Yes, I have
    2. I have not
39. Are you willing and able to utilize public transportation?*

    1. Yes
    2. No
41. By submitting you understand that this is only an application and does not guarantee transportation services. A Department of Transportation Services (DTS) representative should contact you in 3 to 5 business days. The completion of this application does not guarantee approval or utilization of the service. Normally, there is a waiting list for ongoing Vocational Transport. Our DTS representative that contacts you will explain in more detail. Thank you for completing the DTS questionnaire.
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43. 1. Receive an email copy of this form.
44. Email address

    This field is not part of the form submission.

45. Submit

* indicates a required field