Travel Training Referral Form
Free One-On-One Training on How to Ride the Bus
Questions? Call us at 253.984.8208
Date
/
Month
/
Day
Year
Who is completing this form?
I'm completing this form for myself.
I'm completing this form for someone else.
Please tell us your name:
First Name
Last Name
Birthdate
/
Month
/
Day
Year
Date
Gender:
M
F
Other
Address
Street
Street Address Line 2
City
State
Zip
Email Address:
example@example.com
Phone
Alt. Phone / Emergency Contact
Emergency Contact Name
Relationship
Home Phone
Do you have an ORCA (One Regional Card for All) Card?
Yes
No
When did you last use the bus?
Never or more than 5 years ago
Less than 5 years
What has prevented you from using the bus? How can we assist?
Do you travel independently using public tranportation?
Yes
No
Do you have a disability?
Yes
No
Do you travel with a mobility device or a service animal?
Yes
No
What type of mobility device do you use when you travel?
Cane
Manual Wheelchair
Walker
Powered Scooter
Powered Wheelchair
Crutches
Other
Where would you like to travel using the bus? For example, I'd like to go to the library in Puyallup!
Please use this space to add any other information you feel would be useful
Did someone refer you to participate in Pierce Transit's Travel Training Program?
Yes
No
Name of Referrer and Job Title
Contact Phone Number
Contact Email address
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