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Dial A Ride
Client Registration
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* Indicates required question
Name
*
Your answer
Physical Address (please include apartment number, city and postal code)
*
Your answer
Mailing address if not the same as physical address (please include apartment number, city and postal code)
Your answer
Email (If you don't use email please write NA@email.com)
*
Your answer
Phone Number
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Name and date of birth for all adults in household (type only me if only you)
*
Your answer
Name and date of birth of all children in household (type none if none)
*
Your answer
Do you own a vehicle?
*
Yes
No
Yes but it is out of service
Yes but I am unable to drive
Do you have a disability? Please give brief description.
*
Your answer
Do you require a wheelchair accessible vehicle?
*
Yes
No
Do you require assistance getting in and out of vehicle?
*
Yes
No
Will you have a attendant travelling with you?
*
Your answer
What activities will be your main purpose for using our service? (check all that apply)
*
Employment
Education
Medical
Household Errands
Family
Social/Recreational
Other:
Required
Please provide the name and phone number of your emergency contact person.
*
Your answer
What is your income bracket?
*
$0 - $25,000
$25, 001 - $35,000
$35,001 - $45,000
Above $45,001 annually
Required
BILLING - Please provide the name, phone number, email, and address if a 3rd party will be covering your fees and please have them contact us directly for authorization.
Your answer
How did you hear about us?
Your answer
Agreement: I declare that I do not have access to affordable and/or accessible transportation
*
Yes
No
Date
*
MM
/
DD
/
YYYY
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