Membership Application Form

Name*

First Last

Mailing Address*

Street Address City Province Postal Code

Civic Address (if different from Mailing Address)

Street Address City Province Postal Code

Telephone*

Cell Phone

Other Phone

Email Address

Date of Birth

Number of children in the household

Names & Date of Birth of Children

How did you hear about our service?

Do you own a vehicle?

Yes
No

Do you have a disability?

Yes
No

Do you require the use of a wheelchair accessible vehicle?

Yes
No

Do you have an attendant that will be traveling with you?

Yes
No

If yes, please note that attendants travel for half fare. It is the responsibility of the member to provide the attendant, and the attendant must be present at the time of the pick-up and return.

Please describe any assistance that you might require in order to use our service

What will be your main purpose for using our service?

Medical
Employment
Job Training/Education
Household Errands
Family
Social or Recreational
Other

If Other, please describe

Please list one person as a reference*

Phone number of reference*

Please provide the name of your emergency contact*

Relationship to member

Telephone

Agreement*

I have read the rules and regulations set forth by the Charlotte County Alternative Transportation Association and I agree to abide by these rules and regulations.

I declare that I do not have access to affordable and/or accessible transportation

Yes
No

Date*

Links