Application to Ride

Name*

Today's Date*

Address*

Street Address Township City State ZIP Code

Email*

Home Phone

Cell Phone

Age*

Date of Birth*

Disabled?*

Yes
No

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?*

Yes
No

In Case of Emergency

Contact*

First Last

Relationship*

Phone*

Address*

Street Address City State ZIP Code

Primary Physician*

Phone Number*

Companion Rider (18+ years)

Contact

First Last

Date of Birth

Applicant Eligibility

Please select all that Apply

Senior Citizen (55+)
Disabled Person
Companion Rider
Service Animal

Please select all mobility devices that apply

Wheelchair
XL Wheelchair
Scooter
Walker

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*

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.*

Yes
No

Proof of Residency Upload

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.*

Yes
No

*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.

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.

Signature*

Date*

Comments

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

248-887-4979

Call to Schedule

WOTA Passenger Registration

Passenger Application

In Case of Emergency

Companion Rider (18+ years)

Applicant Eligibility

Call to Schedule

Service Area

Hours of Operation