Rider Application Rider Application Form RIDER INFORMATIONDate First Name Middle Name Last Name Home Phone Cell Phone Email Street Address (including apartment number) Address Line 2 City State Zip Code Date of Birth Gender - Select -MaleFemalePrefer Not to SayIs your primary language English? Yes NoIf “NO”, please list Primary Language: Choose one Ethnic Identity: Hispanic/Latino Not Hispanic/LatinoChoose one or more Racial Identities (regardless of ethnicity): White Asian Black or African American Native Hawaiian or other Pacific Islander American Indian or Alaska Native Do not wish to discloseAnnual Income Level (not used for eligibility purposes). Answering will help us help others: Greater than $21,020 individual or $45,177 household Less than $21,020 individual or $45,177 householdHave you utilized Span Transit in the past? Yes NoIf yes, when? Do you use a cane? Yes NoDo you use a walker? Yes NoPreviousNextEMERGENCY CONTACT INFORMATIONRelationship to Rider Full Name Street Address City State Zip Code Home Phone Cell Phone Is Emergency Contact the Primary Caregiver? Yes NoDo you have any information that would be helpful to know in the event of an emergency (i.e. medical conditions, allergies, etc.)? PreviousNextSERVICE INFORMATIONI would like to request the following services: General Transportation Veterans Transportation Disability Transportation**** Rider requesting service may qualify for a reduced fare if he/she is over the age of 60 or has a verifiable disability. (Note: Residents in certain contract cities are not eligible and other restrictions may apply.) The Disability Certification Form can be found here. The application must be filled out completely and legibly. The enclosed Physician’s Certification of Disability Form must be completed by a doctor or human services professional familiar with your disability. Once completed, please return the form via email (span@span-transit.org), via fax (940-383-8433), via US Mail, or in person (Span, 1800 Malone Street, Denton, TX, 76201).ACKNOWLEDGEMENT I understand my rights and responsibilities for Span Transit Service Span service is public transportation and I will be sharing rides with other passengers Span does not provide emergency services I must pay the Fare each time I board the Span vehicle Three (3) “No Shows” in 30 days could result in a suspension of service Five (5) “Late Cancellations” in a 30 day period could result in a suspension of service Span Transit Operators may arrive 15 minutes before or after the scheduled pick up time Span Transit Operators will only wait 5 minutes from the time they arrive I understand that Span can only transport mobility devices that can fit onto the wheelchair lift If I am required to have a Personal Care Attendant at the time of pickup and do not have one, I will be unable to ride I have read and agree to adhere to the policies of Span. I certify that the information provided in this application is accurate. I understand that false information may result in the denial or annulment of Span Transit services. I further understand that all information will be kept confidential, and only the information required to provide the services I request will be disclosed to those involved in the performance of those services.**Signature Sign Here Date **If someone other than the rider is completing this form or has assisted the rider, that person must complete the following: Full Name Home Phone Signature Sign Here Relationship Cell Phone Date Previous Submit
