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General Public Dial-A-Ride Application

If you live within the Urban Growth Boundary of Canby and would like to register for the General Public Dial-A-Ride service please complete the application below.

Once your application is completed it will be submitted for review to the Transit Operations Manager. You will then be contacted once your application has been processed.

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Applicant Information:

First Name: *

Middle Initial:

Last Name: *

Resident Address: *

Number and Street Address of Applicant

Residence City: *

City of Applicants Home Address

Resident State: *

State of Applicants Home Address

Resident Zip Code: *

Zip Code of Applicants Home Address

Name of Building, Complex or Facility

Name of Building, Complex or Facility that applicant resides in, if applicable.

Mailing Address:

Mailing Address of Applicant, if different than above.

Mailing City:

Mailing City of Applicant, if different than above.

Mailing State:

Mailing State of Applicant, if different than above.

Mailing Zip Code:

Mailing Zip Code of Applicant, if different than above.

Primary Phone Number *

Primary Phone Number to Contact Client

Is this a Cell Phone? *

Yes

Secondary Phone Number

Secondary Phone Number to Contact Client

Is your Secondary Phone a Cell Phone?

Yes

Date of Birth

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Applicants Date of Birth

Email Address

Email Address of Applicant

Do you use any mobility devices? *

Yes

If you use mobility devices what kind?

Are You interested in Paratransit Dial-A-Ride? *

Yes

If you have a medical condition or disability you may qualify for our Paratransit Dial-A-Ride service. Please let us know here if you would like to complete the application for Paratransit Dial-A-Ride service, you can read more about it under our Dial-A-Ride section on the Canby Area Transit website. You can also contact the Transit Operations Manager at 503-266-0717 to see if you would qualify.

Emergency Contact Information:

Emergency contact information if needed for emergency or urgent matters.

Emergency Contacts Full Name *

Full First and Last Name of Emergency Contact

Emergency Contact Primary Phone Number *

Primary phone number for emergency contact.

Secondary Number for Emergency Contact

Secondary Phone Number for Emergency Contact

General Public Dial-A-Ride Application

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Contact Information