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City of Midland Dial-A-Ride Passenger Information Form Date Completed by Passenger: Date received by Dispatch Office: Please print all information clearly Section 1: Passenger Information Please Select : Mr. Mrs. Ms. Miss First Name: Last Name: Home Address: City: Zip: Date of Birth: Additional Information to help our drivers identify where you live (Apt name of building, etc.) Home Phone: Cell Phone: E-Mail Address: Do you need language translation services? Yes No Language Spoken: List the names of two people and/or agency (if appropriate) which may be contacted in case of an emergency Contact 1: Relationship: Phone number: Alterative Phone number: Address: Contact 2: Relationship: Phone number: Alterative Phone number: Address: Section 2: Emergency Contact Information Return this portion to Dial-A-Ride ---PAGE BREAK--- Section 3: Boarding Needs If you have a legal guardian please provide their name and phone number below: Guardian Name: Guardian Phone Number: Please Check if you will be traveling using any of the following mobility devices: Foldable Walker Cane Walker Crutches Manual Wheelchair Guide Dog Electric Wheelchair Grocery Cart Amigo/Power Scooter Oxygen Do you have staff that assists you in scheduling and cancelling your rides? Yes No If so, list the staffing Agency Name: Agency Phone Number: Please list if there is an After-Hours Staff Number: Will staff be traveling with you? Yes No Any other information we should know about while riding with Dial-A-Ride, please check all that may apply : Prone to seizures Other If other Please Explain below: Hearing Impaired Visually Impaired Walks Slowly If there is a problem with your rides who should we contact? Name: Phone: Email: Name: Phone: Email: Reminder: A separate form must be completed for each family member Mail your completed passenger information form to: City of Midland Dial a Ride 333 W. Ellsworth Midland, MI 48640 OR drop off your completed passenger information form to: Municipal Services Center Dial-A-Ride 4811 N. Saginaw Rd Midland, MI 48640 You can also submit your form via email to [EMAIL REDACTED] Or via fax to [PHONE REDACTED] Return this portion to Dial-A-Ride ---PAGE BREAK--- Section 4: Accepting Dial-A-Ride Policies Enclosed in this packet are the following policies: No Show/Cancellation Policy, Passenger Policy, Transportation Requirements, Child/Minor Responsibility Policy. Passengers are required to read these policies and follow them. Please initial below to indicate that you acknowledge receipt of the enclosed policies. I acknowledge receipt of the Dial-A-Ride No Show/Cancellation Policy, the Passenger Policy, the Transportation Requirements and the Child/Minor Responsibility Policy. If you have questions regarding these policies, please contact the Dial-A-Ride Office at [PHONE REDACTED] Section 5: ADA Verification Any passenger (other than senior citizens) who is eligible for the reduced fare ($.75 or pink tickets) under the American with Disabilities Act (ADA) must verify their eligibility. There are two ways to verify ADA eligibility: 1) Visit the Dial-A-Ride office at 4811 N. Saginaw Rd. Midland, MI 48640 during office hours (Mon- Fri, 8am-5pm) and present your red, white and blue Medicare Card along with a valid photo I.D. OR 2) Have a MEDICAL DOCTOR or MENTAL HEALTH PROFESSIONAL complete the following infor- mation: I attest that (passenger name) is eligible for the reduced fare based on their ADA qualifications. Signature: Printed Name of Professional: Agency/Medical practice (if applicable) City: State: Zip: Phone Number: Return this portion to Dial-A-Ride