Application to Ride PF - WOTA

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Please fill in the information below, sign and either email to: [email protected] or mail to: 250 W. Livingston Rd. Highland, MI 48357.

To print, right click and choose Print.

Passenger Application

Passenger Application

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This field is for validation purposes and should be left unchanged.

Name(Required)

Today's Date(Required)

Month

Day

Year

Address of Residence(Required)

Street Address Township City State ZIP Code

Email(Required)

Home Phone

Cell Phone

Age(Required)

Date of Birth(Required)

Month

Day

Year

Disabled?(Required)

Yes

No

Other

Explain "Other" or give more information as appropriate.

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)

Yes

No

In Case of Emergency

Contact(Required)

First Last

Relationship(Required)

Phone(Required)

Address(Required)

Street Address City State ZIP Code

Primary Physician(Required)

Phone Number(Required)

Companion Rider (18+ years)

Contact

First Last

Date of Birth

MM slash DD slash YYYY

Applicant Eligibility

Please select all that Apply(Required)

Senior Citizen (55+)

Disabled Person

Companion Rider

Service Animal

Low Income

Veteran

General Public (18+)

Please select all mobility devices that apply(Required)

Wheelchair

XL Wheelchair

Scooter

Walker

I need to use the lift

No mobility device is needed

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.

For program funding purposes, Race is required(Required)

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)

Yes

No

Stay in the Loop with WOTA

Would you like reminders and updates about your rides? Opt in below and you’ll receive a text or phone call:
* The night before your appointment

* About 15 minutes before your ride arrives

* Any time WOTA is closed

You may opt out at any time, and consent is not required to use the service. Message and data rates may apply.

Please select only one method of contact

SMS Text

Phone

*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.

No, I do not give consent to using my picture for promotional or historical purposes.

Consent to Use Electronic Signature(Required)

By mouse/finger signing, file upload and/or typing my name below, I agree to using an electronic signature

I agree to using an electronic signature.

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.

Yes

Signature

I am uploading my signature instead of finger/mouse signing.

I choose to upload a digital version of my signature

Accepted file types: png, jpg, pdf, doc, docx, Max. file size: 512 MB.

Signature Typed(Required)

Date of Signature(Required)

Month

Day

Year

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.

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