Dial A Ride
Client Registration
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Name *
Physical Address (please include apartment number, city and postal code) *
Mailing address if not the same as physical address (please include apartment number, city and postal code)
Email *
Phone Number *
Date of Birth *
Name and date of birth for all adults in household (type only me if only you) *
Name and date of birth of all children in household (type none if none) *
Do you own a vehicle? *
Do you have a disability? Please give brief description. *
Do you require a wheelchair accessible vehicle? *
Do you require assistance getting in and out of vehicle? *
Will you have a attendant travelling with you? *
What activities will be your main purpose for using our service? (check all that apply) *
Please provide the name and phone number of your emergency contact person. *
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.
Agreement:  I declare that I do not have access to affordable and/or accessible transportation *
Date *
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