WOTA Passenger Registration

Print Friendly Passenger Registration
Low Income Qualification Form
Print Friendly Professional Verification

Please fill in the information below, sign and either submit the online form, or choose the printer-friendly application and email to: info@rideWOTA.org or mail to:  250 W. Livingston Rd.  Highland, MI 48357

Passenger Application

Today's Date(Required)
Address(Required)
Date of Birth(Required)
Disabled?(Required)

West Oakland Transportation Authority (WOTA) requires verification by a professional in order to qualify disabled individuals requesting service for transportation. Please use the Professional Verification form
Are you an Open Door Outreach Center or Hospitality House client?(Required)

In Case of Emergency

Contact(Required)
Address(Required)

Companion Rider (18+ years)

Contact
MM slash DD slash YYYY

Applicant Eligibility

Please select all that Apply(Required)
Please select all mobility devices that apply(Required)
NOTE: For Safety reasons, All Mobility Devices cannot be more that 33 inches wide and/or be more that 1,000 lbs INCLUDING the Passenger while on the lift.
I have included a copy of a driver’s license, state ID or utility bill, etc. in my name or other proof of residency with this form.(Required)
Max. file size: 512 MB.
I certify that the above information is correct and the address is where I reside, And I understand that submitting false information is just cause for refusal of service.(Required)
*PLEASE NOTE: Based on the status of our riders, if you are a regular rider and you are scheduled but you do not call to cancel your ride, you do not answer your phone and nor do you come out when the driver arrives, we reserve the right to call for a non-emergent welfare check to ensure your safety and well-being.
Sometimes WOTA takes pictures of it’s clientele for promotional and/or historical documentation purposes. By signing this form you give consent for WOTA to use your picture in those promotions, unless you check the “no” box.
Consent to Use Electronic Signature(Required)
I am unable to use finger/mouse or file upload to sign and will only type my name in "Signature Typed" box below.
Ignore this input if you plan to sign by finger/mouse or file upload.
Clear Signature
I choose to upload a digital version of my signature
Accepted file types: png, jpg, pdf, doc, docx, Max. file size: 512 MB.
Date of Signature(Required)
I have read and understand the rules and regulations regarding the use of transportation through the West Oakland Transportation Authority (WOTA). By signing this form, I acknowledge I will follow the rules and regulations of scheduling and riding the organization’s vehicles.