Transportation Assistance Hub

Transportation Assistance Hub

Basic Rider Intake
Rider Data Consent

In order to receive specialized services as part of the Transportation Assistance Hub, you must complete the following intake form. The data in this form may be used to create a rider profile and as part of Feonix's metrics and reporting process. Riders will not be identified by name when data is reported. Reponses will be summarized along with others completing this intake. The combined results will give Feonix an idea of how to improve transportation in the community and provide data for fundraising efforts. If you do not wish to participate, you have the right to say no.
Do you consent to Feonix - Mobility Rising using your anonymized data?*

YesNo
Thank you for your response. If you do not wish to complete the intake, you are not eligible for specialized services with Feonix - Mobility Rising, but please feel free to download and use the Feonix Catch A Ride mobile app for other transportation options available in your area.

Who is completing this form?*

RiderCaregiver for riderCommunity Booking Partner on behalf of riderFeonix Staff Member
First Name of Person Completing the Intake Form*
Last Name of Person Completing the Intake Form*

Rider Information
Rider First Name*
Phonetic Spelling of First Name
Rider Last Name*
Rider Phone Number*
Please enter a valid phone number.Format: +10000000000.
Rider Email
We use your email to send important trip information, including any changes to your trips.
Rider Home Address
Rider Home Address

Street Address

Street Address Line 2

CityState / Province

Zip Code
Street Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
City*
State*
State
Zip Code*
What county do you live in?*
Which initiative are you applying to?*
Do you identify as a person with a disability?

YesNoPrefer not to say
Which initiative are you applying to?*
How would you like to schedule your rides? (Check all that apply)*

Call and talk directly with someoneUse a mobile app on my smartphoneDo it myself online using the computer or tabletA third-party organization will be booking my rides
If there's an emergency, who should we contact?
Emergency Contact First Name*
Emergency Contact Last Name*
Emergency Contact Phone Number*
Please enter a valid phone number.Format: +10000000000.
Relationship to Rider

Media Release
Our media release form is completely optional, but it helps us share the impact of our work with the community. As a nonprofit, we rely on grants and donations to keep our services running, and sharing stories from riders like you allows us to show funders why our work matters. Your support in spreading the word helps us continue providing transportation to those who need it most!
Would you like to sign our optional media release form?*

YesNo
Signature*
I, the undersigned, hereby grant permission to Feonix - Mobility Rising, its representatives, employees, agents, and partners the irrevocable and unrestricted right to use, reproduce, and publish my photos, videos, and interviews for the purpose of publication, promotion, illustration, advertising, or trade, in any manner or in any medium.

I hereby waive any right to inspect or approve the finished photographs or electronic matter that may be produced using them now or in the future, whether that use is known unknown to me. I also waive any right to compensation and release Feonix - Mobility Rising from any and all liability which may arise from the use of such media.

By signing this release you are recognizing that you are at least 19 years old or the legal parent of guardian of the subject who is under 19 years old, have read and understood the previous statements, and are able to contract in your own name.

Rider Data Consent