Dial-A-Ride Registration

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Age/Disability Attestation *

Select all that apply:

I am age 60 or older

I am age 60 or older and identify as an individual with disabilities

I am under age 60 and identify as an individual with disabilities (please fax letter from doctor attesting disability) 860-870-6644

Phone *

(###)

###

####

Preferred Contact Method *

How can our dispatchers best reach you?

Phone

Text

Email

Ethnicity *

Hispanic/Latino

Not Hispanic/Latino

Race *

White

Black/African American

Asian

Other

Emergency Contact *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Housing *

Private Home

Private Apartment

Senior Housing

Congregate Housing

Public Housing

Residential Care Home

Nursing Home

Assisted Living

Living Arrangement *

Alone

With Spouse/Partner

With Spouse and Child/Children

With Child, No Spouse/Partner

With Relative

With Others

Mobility Devices *

Do you require any of the following mobility devices, such as:

I do not require the use of a mobility device

Wheelchair

Cane

Crutch

Walker

Scooter

Do you require an aid or escort? *

Yes

No