RiderAgreement RIDER AGREEMENT FORM Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name: *FirstLastSalutation: *MrMrsMsDrRevOtherIf you chose Other, please describe here: Address: *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone (Primary): *Phone (Alternate):Email: *Date of Birth: *Gender: *MaleFemaleLive Alone: *YesNoMarital Status: *MarriedDomestic PartnerDivorcedWidowedSinglePlease indicate any mobility aids, medical equipment or other assistance that you need: *WheelchairWalkerCaneCrutchesAttendantService AnimalOxygenNoneOther (Please describe)If you chose Other, please describe here:First Emergency Contact Name: *FirstLastRelationship with First Emergency Contact: *First Emergency Contact Address: *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeFirst Emergency Contact Email:First Emergency Contact Primary Phone: *First Emergency Contact Alternate Phone:Second Emergency Contact Name: FirstLastRelationship with Second Emergency Contact: Second Emergency Contact Address:Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeSecond Emergency Contact Email: Second Emergency Contact Primary Phone:Second Emergency Contact Alternate Phone:Third Emergency Contact Name: FirstLastRelationship with Third Emergency Contact: Third Emergency Contact Address:Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeThird Emergency Contact Email: Third Emergency Contact Primary Phone:Third Emergency Contact Alternate Phone:Please check the following to continue: *I certify that I am a Ridgefield senior citizen (60 years or over) or a Ridgefield resident who has a mobility disability (unable to drive for medical reasons).Further, I certify that I am self-sufficient, have limited need for assistance, or will be accompanied by an aide or companion who will assist me.Further, I agree to abide by the Rider Guidelines established by Rides For Ridgefield (see above).Further, I understand that Rides For Ridgefield may periodically update this Rider Agreement and Rider Guidelines and I may be asked to sign the updated Agreement.Further, I authorize Rides For Ridgefield to contact my emergency contacts in the event of a non- response to a scheduled ride or an emergency.Signature * Clear Signature Date Signed *Click on the box to select dateSubmit