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Senior Transit for Area Residents (STAR) Application

2. STAR Program Application
   Please complete the information requested on the STAR application and a Human Services staff member will follow up with you for a telephonic interview. You will be asked to provide proof of age, current proof of residency, and proof of ADA Paratransit Certification (if applicable) to Skokie Human Services. You may upload these documents to your application at the very bottom. Human Services will assist you if you are unable to do this.

   Please complete the information requested on the STAR application and a Human Services staff member will follow up with you for a telephonic interview. You will be asked to provide proof of age, current proof of residency, and proof of ADA Paratransit Certification (if applicable) to Skokie Human Services. You may upload these documents to your application at the very bottom. Human Services will assist you if you are unable to do this.

3. 

5. Program brochure and PDF application:
   Click here to view the program brochure and PDF version of the application.

7. Name: *

   First, Middle Initial, Last

9. Address:

11. City:

12. Zip Code:

14. Phone Number:

15. Email:

17. Age:

18. Date of Birth:

    Example: 01/01/1995

20. Emergency Contact Information:

22. Emergency Contact #1:

    Name, Relationship

24. Phone:

    Please include area code

25. Cell Phone:

    Please include area code

27. Address:

28. City and State:

30. Emergency Contact #2:

32. Phone Number:

    Please include area code

33. Cell Phone:

    Please include area code

35. Address:

36. City/State:

38. Physician’s Name:

39. Phone:

41. To meet Federal funding requirements answers to the following questions are needed. (Your answers will not affect your eligibility for the STAR Program.

43. Sex:

    1. Male
    2. Female

45. What is your race?

    1. White
    2. Black/African America
    3. Asian
    4. American Indian/Native Alaskan
    5. Native Hawaiian/Other Pacific Islander

    1. Asian & White
    2. Black/African American & White
    3. American Indian/Native Alaskan & Black/African-American
    4. Other multirace

47. Are you Hispanic?

    1. Yes
    2. No

49. How many members are in your household?

51. Gross household income is:

    1. At or below $15,850
    2. Between $15,850 and $26,400
    3. Between $26,400 and $42,200
    4. Over $42,200

52. Actual income (optional):

54. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
56. Electronic Signature*

58. If possible, please upload proof of age, current proof of residency, and proof of ADA Paratransit Certification (if applicable)

60. For a telephonic interview, please call 847-933-8208

Leave This Blank:


62. 1. Receive an email copy of this form.
63. Email address

    This field is not part of the form submission.

64. Submit Submit and Print

* indicates a required field