{"id":583,"date":"2024-08-15T15:29:01","date_gmt":"2024-08-15T19:29:01","guid":{"rendered":"https:\/\/www.coshoctoncounty.net\/transportation\/?page_id=583"},"modified":"2024-08-15T15:29:01","modified_gmt":"2024-08-15T19:29:01","slug":"new-rider-account-setup","status":"publish","type":"page","link":"https:\/\/www.coshoctoncounty.net\/transportation\/new-rider-account-setup\/","title":{"rendered":"New Rider Account Setup"},"content":{"rendered":"\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f579-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"579\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/transportation\/wp-json\/wp\/v2\/pages\/583#wpcf7-f579-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"579\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.5\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f579-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/><input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/fieldset>\n<p>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 phone call from a Dispatcher to explain our guidelines!\n<\/p>\n<p><label> Name <span class=\"wpcf7-form-control-wrap\" data-name=\"firstName\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"First\" value=\"\" type=\"text\" name=\"firstName\" \/><\/span> <\/label><br \/>\n<label> <span class=\"wpcf7-form-control-wrap\" data-name=\"middleName\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Middle Initial\" value=\"\" type=\"text\" name=\"middleName\" \/><\/span> <\/label><br \/>\n<label> <span class=\"wpcf7-form-control-wrap\" data-name=\"lastName\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Last\" value=\"\" type=\"text\" name=\"lastName\" \/><\/span> <\/label>\n<\/p>\n<p><label> Date of Birth <span class=\"wpcf7-form-control-wrap\" data-name=\"DateofBirth\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"DateofBirth\" \/><\/span> <\/label>\n<\/p>\n<p><label> Age <span class=\"wpcf7-form-control-wrap\" data-name=\"age\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"age\" \/><\/span> <\/label>\n<\/p>\n<p><label> Gender <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"Gender\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"Gender\" value=\"Male\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Male<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"Gender\" value=\"Female\" \/><span class=\"wpcf7-list-item-label\">Female<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"Gender\" value=\"Unspecified\" \/><span class=\"wpcf7-list-item-label\">Unspecified<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p><label> Address <span class=\"wpcf7-form-control-wrap\" data-name=\"AddressLine1\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Address Line 1\" value=\"\" type=\"text\" name=\"AddressLine1\" \/><\/span> <\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"AddressLine\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Address Line 2\" value=\"\" type=\"text\" name=\"AddressLine\" \/><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"City\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"City\" value=\"\" type=\"text\" name=\"City\" \/><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Zip\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Zip Code\" value=\"\" type=\"text\" name=\"Zip\" \/><\/span>\n<\/p>\n<p><label> Mobility Needs: <span class=\"wpcf7-form-control-wrap\" data-name=\"Mobility\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"Mobility\"><option value=\"Ambulatory (can walk and use steps)\">Ambulatory (can walk and use steps)<\/option><option value=\"Manual Wheechair, but could transfer into seat\">Manual Wheechair, but could transfer into seat<\/option><option value=\"Manual Wheelchair, cannot transfer into seat\">Manual Wheelchair, cannot transfer into seat<\/option><option value=\"Power Wheelchair\">Power Wheelchair<\/option><option value=\"Cannot Use Steps, but CAN get into a mini-van\">Cannot Use Steps, but CAN get into a mini-van<\/option><option value=\"Cannot Use Steps, and CANNOT get into a van\">Cannot Use Steps, and CANNOT get into a van<\/option><\/select><\/span> <\/label>\n<\/p>\n<p><label> Language (Optional): <span class=\"wpcf7-form-control-wrap\" data-name=\"Languageoptional\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"Languageoptional\"><option value=\"English\">English<\/option><option value=\"Spanish\">Spanish<\/option><option value=\"Other\">Other<\/option><\/select><\/span> <\/label>\n<\/p>\n<p><label> Race (Optional): <span class=\"wpcf7-form-control-wrap\" data-name=\"Race\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"Race\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"African American\">African American<\/option><option value=\"Asian\">Asian<\/option><option value=\"Caucasian (White)\">Caucasian (White)<\/option><option value=\"Indian\">Indian<\/option><option value=\"Other\">Other<\/option><\/select><\/span> <\/label>\n<\/p>\n<p><label> 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 <span class=\"wpcf7-form-control-wrap\" data-name=\"specialassist\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"If none, type None.\" value=\"\" type=\"text\" name=\"specialassist\" \/><\/span> <\/label>\n<\/p>\n<p><label> Primary Phone Number <span class=\"wpcf7-form-control-wrap\" data-name=\"PrimaryPhoneNumber\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"PrimaryPhoneNumber\" \/><\/span> <\/label>\n<\/p>\n<p><label> Alternate Phone Number <span class=\"wpcf7-form-control-wrap\" data-name=\"AlternatePhoneNumber\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"AlternatePhoneNumber\" \/><\/span> <\/label>\n<\/p>\n<p><label> Social Security Number <span class=\"wpcf7-form-control-wrap\" data-name=\"SocialSecurityNumber\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"SocialSecurityNumber\" \/><\/span> <\/label>\n<\/p>\n<p><label> Email Address <span class=\"wpcf7-form-control-wrap\" data-name=\"Email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"Email\" \/><\/span> <\/label>\n<\/p>\n<p><label> Notes \/ Comments <span class=\"wpcf7-form-control-wrap\" data-name=\"NotesComments\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"NotesComments\"><\/textarea><\/span> <\/label>\n<\/p>\n<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Submit\" \/>\n<\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n\n\n\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":14,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"ngg_post_thumbnail":0,"footnotes":""},"class_list":["post-583","page","type-page","status-publish","hentry","post-preview"],"_links":{"self":[{"href":"https:\/\/www.coshoctoncounty.net\/transportation\/wp-json\/wp\/v2\/pages\/583","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.coshoctoncounty.net\/transportation\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.coshoctoncounty.net\/transportation\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.coshoctoncounty.net\/transportation\/wp-json\/wp\/v2\/users\/14"}],"replies":[{"embeddable":true,"href":"https:\/\/www.coshoctoncounty.net\/transportation\/wp-json\/wp\/v2\/comments?post=583"}],"version-history":[{"count":4,"href":"https:\/\/www.coshoctoncounty.net\/transportation\/wp-json\/wp\/v2\/pages\/583\/revisions"}],"predecessor-version":[{"id":598,"href":"https:\/\/www.coshoctoncounty.net\/transportation\/wp-json\/wp\/v2\/pages\/583\/revisions\/598"}],"wp:attachment":[{"href":"https:\/\/www.coshoctoncounty.net\/transportation\/wp-json\/wp\/v2\/media?parent=583"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}