New Rider Account Setup

If you are new to CPT please complete this form prior to Scheduling a Ride!

Name

Date of Birth

Age

Gender MaleFemaleUnspecified

Address

Mobility Needs: —Please choose an option—Ambulatory (can do steps)Manual WheelchairPower WheelchairLift Required (Cane, Walker, etc.)

Language (Optional): EnglishSpanishOther

Race (Optional): —Please choose an option—African AmericanAsianCaucasian (White)IndianOther

Special Assistances - Please list any that apply to you: Cane, Crutches, Dementia, Hearing Impaired, Oxygen, Service Animal-going on trip with you, Vision Impaired, Walker

Primary Phone Number

Alternate Phone Number

Social Security Number

Email Address

Notes / Comments