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2. Today's Date*
   Today's Date
3. Date of Birth*
   Date of Birth
4. Gender*

   1. Male
   2. Female
6. First Name*
7. Last Name*
9. Address*
10. Apt./Unit #
12. City*
13. State*
14. Zip*
16. Primary Phone Number*
17. Secondary Phone Number
21. Section I: Valid Identification & Proof of Residency
23. 
25. Identification*
    Upload an acceptable form of identification
26. Proof of Residency*
    Upload proof of residency
30. Section II: Emergency Contact Information
    Please provide a name and telephone number of a contact person in the event of an emergency.
32. Name*
33. Day Phone*
35. Relationship*
36. Evening Phone
40. Section III
    Please answer the following questions - your specific answers to the questions will familiarize us with your individual needs.
42. 1. What is your disability or health related condition that prevents you from using public transportation*
44. 2. Explain how your disability or health related condition prevents you from independently using the public transit services (BART, AC Transit, etc)*
46. 3. How do you currently travel to your destinations? Check all that apply. *

    1. Public Buses
    2. Paratransit
    3. BART

    1. Someone Provides Transportation
    2. Taxi
    3. Lyft/Uber

    1. Drive Myself
    2. Ferry
    3. Other
48. 4. Do you use any of the following mobility aids or specialized equipment? Check all that apply.

    1. Cane
    2. White Cane
    3. Walker
    4. Leg Braces

    1. Power Wheelchair
    2. Large Power Wheelchair
    3. Power Scooter (3-wheeler)
    4. Manual Wheelchair

    1. Communication Board
    2. Service Animal
    3. Crutches
    4. Other Aid
50. Does your residence have a ramp to accomodate your wheelchair or scooter?*

    1. Yes

    1. No
52. Does the wheelchair or scooter have a seatbelt?*

    1. Yes

    1. No
54. Can your manual wheelchair be folded?*

    1. Yes

    1. No
56. 5. Can you transfer into a vehicle with minimal assistance?*

    1. Yes

    1. No
58. 6. Does a personal care attendant accompany you when you travel outside the home?*

    1. Yes

    1. No
62. Section IV
    Age and Disability verification
64. I am *
    -- Select One --age 55 or olderbetween the ages of 18-54
66. Proof of disability

    Applicants between the ages of 18-54 must provide proof of disability. Select the proof of disability you will provide:

    1. Scan of Medicare card (federally-issued red, white and blue card)
    2. Scan of California DMV Disabled Placard Registration Parking Placard Receipt
    3. Scan of Regional Transit Connection (RTC) Clipper Card
    4. Scan of certification proof with East Bay Paratransit
    5. Authorization for Use or Disclosure of Patient Health Information Form. This form authorizes R-Transit to obtain information from your physician regarding your disability
    6. Disability Verification completed by Healthcare Provider
68. Medicare card*
    Upload a scan of your Medicare card in jpg format
70. DMV Disabled Placard Parking Receipt*
    Upload a scan of your receipt in pdf or jpg format
72. Regional Transit Connection Clipper Card*
    Upload a scan of your RTC card in jpg format
74. East Bay Paratransit Certification*
    Upload a scan of your certification with East Bay Paratransit in pdf format
76. Authorization for Use or Disclosure of Patient Health Information
    Authorization for Use or Disclosure of Patient Health Information

    The link above will open in a new window and allow you to print the Authorization for Use or Disclosure of Patient Health Information form. This form authorizes R-Transit to obtain information from your physician regarding your disability. Once completed and signed, you will scan the form below.
78. Authorization for Use or Disclosure of Patient Health Information*
    Upload your signed form in pdf format
80. Disability Verification completed by Healthcare Provider
    Disability Verification Form

    The link above will open in a new window and allow you to print the Disability Verification form. This form must be filled out by your healthcare provider. You may upload the completed and stamped form below.
82. Disability Verification completed by Healthcare Provider*
    Upload the completed and stamped form in pdf format
86. Section V: RAPID: On Demand Service with Lyft
88. The City of Richmond has contracted with Lyft to provide on demand transportation service for registered R-Transit clients. The R-Transit program’s newest addition, RAPID, will offer R-Transit clients a subsidy to use Lyft. Lyft is a ridesharing application that connects people with a nearby driver and transports them to their destination. Lyft is not a replacement for an ambulance, and should not be used as a means of emergency transport.
90. Lyft is best suited for those comfortable with boarding vehicles (including SUVs and vans) without driver assistance. Due to the nature of Lyft, drivers are not required to assist passengers in and out of the vehicle, assist with personal belongings, or walk passengers to their destination. Lyft’s policy is that passengers who use wheelchairs that can safely and securely fit in the car’s trunk or backseat without obstruction the driver’s view will be accommodated by the Lyft driver. R-Transit clients who are able to fold and store their wheelchair on board without the assistance of drivers and able to transfer in and out of the vehicle independently or with the assistance of an accompanying assistance can use Lyft.
92. To use the RAPID, R-Transit clients will need a smart phone, and a credit/debit card. RAPID will allow R-Transit clients to receive a subsidy to use Lyft for a maximum of forty (40) one way trips per month. R-Transit clients will pay $3.00 for each one-way trip within the service area and the City of Richmond will cover the remaining fare up to $17.00 per one-way trip. If the total cost of the trip exceeds $20.00, the client will be responsible for the overage. R-Transit’s service area includes: Richmond, El Cerrito, North Richmond, Kensington, El Sobrante, San Pablo, and Pinole. RAPID will also expand service to and from the Regional Contra Costa Medical Center and Veterans Hospital in Martinez, CA.
94. 1. Do you plan on using Lyft?*

    1. Yes
    2. No
96. Waiver of liability
    Waiver of Liability

    The link above will open in a new window and allow you to print the waiver of liability form. This form must be on file with R-Transit to use RAPID. Once you submit this application, please allow up to 10 business days for processing.
98. RAPID Registration*
    Upload the registration form here. The registration form is the first page of the Waiver of Liability form.
99. Waiver of liability*
    Upload the waiver of liability form here (page 2 of the Waiver of Liability form)
101. 2. Do you currently use or have you used a ride sharing service (Lyft, Uber, Go Go Grandparent, etc.)?*

     1. Yes
     2. No
103. If yes, which one?*
105. 3. Have you installed the Lyft app on your smart phone?*

     1. Yes
     2. No
107. If yes, the phone associated with my Lyft app is:*
109. If no, do you need assistance with installing the Lyft app on your smart phone?*

     1. Yes
     2. No
113. Section VI
115. Applicant Certification*

     By checking the box and typing my name below, I am electronically signing my application. I understand all information will be kept confidential and only the information require to provide the services will be disclosed to those who perform the service.

     1. I certify that the information on this form is true and correct. I understand falsification of information may result in denial of service.
117. First Name*
118. Last Name*
Leave This Blank:


122. 1. Receive an email copy of this form.
123. Email address

     This field is not part of the form submission.

124. Submit Submit and Print

* indicates a required field