Register to Ride

Name*

First Last

Address*

Street Address Address Line 2 City ZIP / Postal Code

Cell Phone*

Land Line Phone Number

Email*

Date of Birth*

Please enter a number from 0 to 12312050.

Gender*

Male
Female
Prefer not to say

Do you have a disability?*

Yes
No

Nature of Disability*

Select All
Mobility
Cognitive
Visual
Other

Mobility Aid*

Do you and your wheelchair weigh more than 600 lbs?

No
Yes

Are you able to ride Get About without assistance?*

Yes
No

Do you use transportation outside the Get About service area?

Yes
No

The Get About service area covers the communities of Pomona, Claremont, La Verne, and San Dimas.

Emergency Contact Name*

First Last

Emergency Contact Phone*

Signature*

By typing your name above, you are providing a digital signature, and asserting that the above information is true to the best of your ability.

Parent/Guardian Signature Required

If you are under 18, you must provide the signature of a parent or guardian. Please contact PVTA office to complete registration 909-596-7664 opt 0 or [email protected]

Parent/Guardian Phone Number

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Phone

This field is for validation purposes and should be left unchanged.

Rider Registration Form