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Dial-A-Ride

Date of Birth:* (required)

* Proof of disability OR age (65+) is required. Please mail to 633 E. Broadway, Room 300, Glendale, CA 91206 or fax documents to the City of Glendale at (818) 409-7027.

Gender:

Male

Female

Title: (required)

First Name: (required)

Last Name: (required)

Home Phone:* (required)

( ) -

Cell Phone:

( ) -

Current Address: (required)

Apt. or Unit No.:

City: (required)

Zip Code:

Type of Residence:

	Home
	Apartment
	Condo
	Retirement Residence
Other:

Field Check (Do you live on a steep hill?):

Yes

Where do you travel to the most?

Examples: your primary doctor�s office, dialysis center, care facility, workshop, etc.

Destination #1:
Address:
Phone Number:
Destination #2:
Address:
Phone Number:
Destination #3:
Address:
Phone Number:

Do you require an attendant?

Yes

Nature of Disability:

Language:

	English
Other:

If you use a wheelchair, is it:

	Manual
	Electric
	Scooter

Do you use a:

	Cane
	Walker
	Crutches
	Service Animal

Hard of Hearing:

Yes

Legally Blind:

Yes

Additional Comments:

In case of emergency notify:

Name: (required)

Phone: ( ) - (required)

Relationship: (required)

Name:

Phone: ( ) -

Relationship:

Last modified: Wednesday, February 01, 2012 6:02:25 PM