Online In-take Form Please answer all of the questions below to share your rider profile. Rider Name [First and Last)(required) Email(required) Date of Birth (MM/DD/YYYY) Must be 18 years or older, or accompanied by legal guardian.(required) Do you have a medical Diagnosis for a physical or cognitive disability? If yes please explain?(required) If you responded no to the previous question but still believe that you qualify for this resource please explain why in the blank below? How will you pay for this service? (EX: IRIS funding or Private Pay)(required) If you’re using IRIS, please state who your IC (IRIS Consultant) is and give us their email: Do you give us permission to contact them to discuss funding? Do you require/ or use a physical support such as a cane, walker, crutch, wheelchair, or other automated device?(required) Will you be riding alone or with care giver assistance? If you are riding with a caregiver, respite provider, family friend, service animal etc. What is the name of your riding companion?(required) What form of transit do you currently use or are comfortable with? Please explain your likes and dislikes below:(required) What is your level of proficiency in the English language? (Intermediate, fluent, or none.) Do you require a translator? If so what is your native language?(required) Is the individual filling out this form the person receiving this training?(required) Submit Δ Share this:TwitterFacebookLike this:Like Loading...
