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Dial-A-Ride Application
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Mass Transit
Kealy Salomon, Commissioner
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Dutchess County Dial-A-Ride Application



Part 1. The use of the information you provide on this form is intended for the sole purpose of registering you for Dial-A-Ride service and to assist in effectively providing the service. Dutchess County will not release this information, except to the sponsoring town, for other purposes without your written consent.

First Name:  (Required)

Last Name:  (Required)

Street Address:

City:                  State:                  Zip Code:

Telephone:  (Required)

Date of Birth:   Month          Day          Year

Municipality of Residence:   (Required)

Nearest Intersection:



Part 2.  Please check any of the following that apply.

It is significantly diffcult for me to:
  Walk more than 200 feet
  Stand outside more than 10 minutes
  Climb a flight of stairs
  Get on or off a standard bus
  Stand on a moving bus
  Read information due to visual impairment
  Hear announcements made by the bus driver

Do you use any of the following aides? (Check all that apply)
Wheelchair              Scooter              Walker             Other  

Do you require a personal care attendant?   Yes    No

Do you need help with packages on and off the bus?   Yes    No

Do you have special needs the dispatcher should be aware of when scheduling your trips?   Yes    No
If yes, please explain:



Please provide the name of a person who could be contacted incase of an emergency:

Name:

Address:

City:       State:       Zip Code:

Telephone:




Part 3.  I state that the information provided on this form is true and complete to the best of my knowledge and agree to release it to Dutchess County for the purpose of establishing my eligibility.

 

 

 


 

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