Rider Application

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Please complete one form per rider
Mailing Address (if different than street address)

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First Emergency Contact
Second Emergency Contact

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Referral: If referred, name of person who made the referral:
Would you like us to send information about this organization to a relative, friend, or business?

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ITNAmerica and this organization respects your privacy and will keep all customer information confidential. The following information allows us to provide better service to our customers, and helps us better understand the circumstances that customers face when they apply to use this organization for rides.

Demographic Info

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Civic Engagement

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Completing the following sections on Mobility Aids, Service Needs and Special Needs will help us serve you better.

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If you do not drive
If you drive...
How often do you _________? (please answer each statement)

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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.

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.