Fill out the form below to register with Senior Express!

Complete the form below or fill out this form to register with Senior Express. Please either pay the one time $15.00 registration fee either through pay pal or mail in your check to Senior Express at 408 Sassafras Court, Bel Air MD 21015.



Passenger Name (required)

Your Email (required)

Home Address

Name of Development

Phone Number

Date of Birth

Will Anyone Be Traveling With You?

Name Of Person Traveling With You

Please List Any Special Needs The Driver Should Be Aware Of

Please List Any Residential Information The Driver Should Be Aware Of

Do You Speak English

If No, Please List Your Language and the Contact Information of Somebody That Can Communicate For You

How Did You Find Out About Us

Emergency Contact

Emergency Contact - Address

Emergency Contact - Relationship To Passenger

Emergency Contact - Phone Number

Passenger Waiver Form

I understand and expressly assume all the dangers of transportation using Senior Express, Inc. I waive all claims arising out of the transport, whether caused by negligence, breach of contract or otherwise, and whether bodily injury, property damage, loss or otherwise, that I may ever have against Senior Express, Inc., its successors and assigns, its officer, directors, agents, volunteers, employees, and their executors, administrators and heirs.

I understand that in the case of a medical emergency, the driver is instructed to call 911 and follow any directions that are provided. The driver’s policies and procedures will be provided to me upon request.

I WILL pay for parking or tolls that are required of any trip requested.

Signature

Date