Application for Transportation Service

Page 1

Please complete one form per rider

Type of Membership:

IndividualFamily

Is this application for:

1st Family Member2nd Family Member

Name of 1st Family Member

IMPORTANT NOTE: For a 2^nd family member, please do not reenter the email you used on the 1^st family member’s account. It is important that you do not use the 1^st family member’s email for the 2^nd family member or the Emergency Contacts. Please just leave the email field blank. Thank you!

Person completing this form is:

RiderFamily MemberOther

Title:

First Name:

Last Name:

Suffix:

Preferred Name (if different than First Name)

Address Line 1:

Address Line 2:

City:

State:

Zip Code:

Is this your mailing address:

YesNo

Mailing Address (if different than street address)

Address:

City:

State:

Zip Code:

Preferred Phone Type:

Mobile:

Home:

Email:

Site Info

Site ID

Site Name

Site Address

Site City

Site Phone #

Individual Membership

Half Family Membership

Site Email

Page 2

First Emergency Contact

Title

First Name

Last name

Suffix

Relationship

Street Address

City

State:

Zip

Preferred Phone Type

Mobile

Home

Email Address

Do you have a second Emergency Contact?

YesNo

Second Emergency Contact

Title

First Name

Last name

Suffix

Relationship

Street Address

City

State:

Zip

Preferred Phone Type

Mobile

Home

Email Address

Bill to info

Would you like your bills to be sent to someone other than the member rider?

YesNo

Is your "Mail to" one of your Emergency Contacts?

YesNo

Please mail my bill to:

Emergency Contact #1Emergency Contact #2

Mail to: (if different than Member/Rider)

Title

First Name

Last name

Suffix

Street Address

City

State:

Zip

Preferred Phone Type

Mobile

Home

Email Address

Page 9

Informed Consent

The Independent Transportation Network (ITN) is a nonprofit, community-based organization providing dignified, consumer-oriented transportation for seniors and people with visual impairments.

As an ITNCountry community, this organization benefits from more than a decade of research to develop a model for economically sustainable transportation. Among the public and private organizations that have supported this research are the Federal Transit Administration, the Transportation Research Board (National Academies of Science), AARP, the Great Bay Foundation for Social Entrepreneurs, and the Atlantic Philanthropies. Thousands of private individuals and their families have participated in this research and development, without which, this service would not be possible.

In the spirit of this public/private effort, to continue the development and analysis that will allow ITNAmerica to better understand the mobility needs of older Americans, their families and their communities, and to continuously improve the quality and sustainability of the service, we routinely collect data about riders and the rides we deliver. The identity of our riders is kept entirely confidential in all reports we use for these purposes.

In addition to this routine data collection, ITNAmerica also conducts research. From time to time, we may ask you to participate in a research project. Your participation in the ITNAmerica research studies is voluntary and confidential. If you prefer not to participate in the research studies, your decision will not affect the quality of your service or your eligibility to use ITN for rides.

Your signature indicates that you understand that routinely-collected ITNAmerica data will be used to study and improve transportation for seniors, and that you may, from time to time, be asked questions about your use of the service. We will do our best to provide rides for you and we will always strive to inform you when we cannot provide a ride. However, we are not responsible for any costs or expenses you may incur when we are unable to provide a ride for a specific time and place.

By typing your name in the box below and submitting this form, you agree that your digital signature will be considered your legal signature and represents your agreement to the terms and policies outlined above.

Agreement Signature:

Agreement Date:

Page 10

"Organization" in this agreement refers to:

Personal Transportation Account Agreement

A personal transportation account is like a personal bank account. It is debited whenever you take a ride with Organization, and when you make a payment to Organization, it is like making a deposit into your account. At the end of each month, you receive a statement that details your rides and any other account activity, such as payments, gift certificates, Ride & Shop" or Healthy Miles", volunteer credits, CarTrade" credits, or payment of membership dues.

Organization is a charitable nonprofit service supported by your fares and voluntary local community support. Because fares cover only half the true cost of rides, the Organization may include family members and any others you have listed as contacts in its fundraising campaigns, including the Family Membership Campaign, Walk for Rides and Annual Appeal. Participation in these campaigns is voluntary. A contact’s decision not to participate will not affect the quality of your service or your eligibility to use Organization for rides.

Your signature below indicates that you agree to the following policies:

You will maintain a balance in your account sufficient to cover your monthly rides;
Your membership dues will be automatically debited on the anniversary of your membership;
If you have an unpaid balance greater than allowed by this site for longer than 60 days, your account will be paused until you have deposited sufficient funds to again achieve a positive balance;
If there is no activity in your account for one year and we have made three documented unsuccessful attempts to reach you, you agree that the balance in your account will become a charitable gift to Organization;
Your contacts may receive a limited number of mailings (via regular mail or e-mail) for the ITN affiliate’s fundraising events/campaigns, as well as up to four quarterly Organization Newsletters. Their names will not be shared with any other party or organization.

By typing your name in the box below and submitting this form, you agree that your digital signature will be considered your legal signature and represents your agreement to the terms and policies outlined above.

Agreement Signature:

Agreement Date:

When you click Review and Submit below, you will be able to review your application before final submission. You must click Confirm on the Review page for your application to be complete.

AARP	Agency on Aging	Employer
Family member	Flier/Brochure	Friend
Health care professional	Internet	ITN customer
ITN staff/board member	ITN volunteer	Newspaper/Magazine
Place of Worship	Radio	Social worker
Speaker/Presentation	Television	Trade Show
Other

ITN Website	Online article/blog/white paper
Social Media – Facebook	Social Media – Twitter
Social Media - LinkedIn	Google (or other search engine)
Other - Internet

Married	Widowed	Divorced
Partnered	Separated	Single

White	Black or African-American
Asian	American-Indian or Alaska Native
Native Hawaiian or Other Pacific Islander	Some other race or ethnicity

English	Spanish	Chinese	French
Japanese	Korean	Tagalog	Vietnamese