New Rider Account Setup

If you are new to CPT please complete this form or call 740.622.7139 prior to Scheduling a Ride! Please expect a follow up email/phone call from a Dispatcher to explain our guidelines!

Name

Date of Birth

Age

Gender MaleFemaleUnspecified

Address

Mobility Needs: Ambulatory (can walk and use steps)Manual Wheechair, but could transfer into seatManual Wheelchair, cannot transfer into seatPower WheelchairCannot Use Steps, but CAN get into a mini-vanCannot Use Steps, and CANNOT get into a van

Language (Optional): EnglishSpanishOther

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

Do You Live Alone? YesNo

Is Your Income less than $1,300/month? YesNo

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
Are you considered Disabled by a Medical Professional? YesNo

Emergency Contact Name

Emergency Contact Phone#

Email Address

Notes / Comments