New Rider Application
Ride Assist Naperville (RAN) - Once filled out, our office will call you to confirm receipt and start the approval process.
Customer Details:
Rider Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mobile Phone Number
Home Phone Number
Please enter a valid phone number.
Client E-mail
example@example.com
County:
Please Select
DuPage County
Will County
Township:
Please Select
DuPage Township
Lisle Township
Naperville Township
Wheatland Township
Subdivision or Apartment Complex Name if applicable
Birthdate
*
-
Month
-
Day
Year
Date
Race/Ethnicity: (Optional)
Are you a veteran?
Yes
No
How did you hear about us?
*
Please Select
Friend/Family
Online Search
Newspaper
Other
Please Specify
*
What best describes your income level? (To be used for grant writing purposes only)
$0-18,750
$18,751-$31,200
$31,201-$49,950
$49,951+
Emergency Contact Information
*
First Name
Last Name
Emergency Contact Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Phone Number
*
Please enter a valid phone number.
Emergency Contact Email
example@example.com
Relationship to Emergency Contact
Additional Information:
Rider Release
In consideration for assisting me in obtaining transportation to and from my medical/dental appointments, I hereby waive and release Ride Assist Naperville (RAN) and its officers, directors, board members, employees, and volunteers ("Released Parties") from all liability with respect to said transportation and the arrangement for said transportation and agree to hold harmless each of the Released Parties from claims arising from this service. My signature below indicates my agreement to the organization's guidelines and client release. It also indicates my understanding that using RAN services, I voluntary assume all risks related to exposure to COVID19.
Signature
*
Date
*
-
Month
-
Day
Year
Date
Please verify that you are human
*
Continue
Continue
Should be Empty: