Rider Registration Form River Cities Public Transit Veteran Transportation Fill out and submit your Rider Registration Form Today's Date:* MM slash DD slash YYYY Date to begin riding:* MM slash DD slash YYYY Passengers Name:* First Middle Last Address:* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Birth Date:* MM slash DD slash YYYY Age:*Male or Female?:* Male Female Cell Phone:Home Phone:*Walk-On or Use of Mobility Device?:* Walk-On Mobility Device Ethnicity:* Caucasian Hispanic African American Native American Medicaid?* Yes No Medicaid #:Additional Comments?:Legal Guardian (if applicable)This will be the person we contact with any issuesName: First Last Address: Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone:Email Address: In Case of EmergencyName of Local Friend or Relative: Relationship to Passenger: Phone:Passenger and/or Legal GuardianPlease read and check each box below: I hereby acknowledge that River Cities Public Transit has a no refund policy on ALL fares. Lost fare cards will cost a extra fee to make another one although the original fare will still be attached to the name of the client. I understand that lack of payment will cause interruption in service. I understand that payment is to be made either in advance or upon boarding the bus. I understand that I need to pre-schedule (by 9pm the night before) to receive discount rates. I understand RCPT's no show policy(I may incur additional fees & 3 no shows in a row will cancel my standing). I understand upon no showing RCPT will remove the no show fee from my fare card or attach it to my next ride. I understand that any cancelations must be made a minimum of 1 hour prior to requested pick up times. I understand that altering a prescheduled ride must be made by 9pm the day before or I risk paying the same day fare. I understand that I am responsible for updating my personal information as needed(i.e. change of address or phone number). I understand that RCPT reserves the right to refuse service. I understand that RCPT is committed to providing NON-discriminatory service & that I may call the office with concerns. No Show and Cancellation Agreement* I Agree In an effort to provide excellent customer service to all of our clients, and to provide the best possible transportation services, it is our policy to require a fee for a no showed ride. Please keep in mind you can cancel up to 1 hour before the scheduled ride with our office (605) 945-2360 or on the Shah My-Ride App without being assessed a no show fee. It is your responsibility to call us and cancel in advance. The fee to be deducted will be the amount of the no showed ride and will be deducted from your fare card. In the event you do not have a fare card a no show fee will be added to your next ride or be added to your profile. Before riding again the no show fee will need to be paid in full or no transportation will be given. The above information is true to the best of my knowledge.:* Yes, I confirm. Parent/Guardian Signature:*Date:* MM slash DD slash YYYY
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