Serving Frederick County, MD

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240-657-3090

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Passenger Registration

Home > Passenger Registration

Online Passenger Registration Form

In order to establish eligibility, please complete the form listed below to register to be a passenger of Rides for Good.
All information collected is considered private and will not be shared with any one or organization.
Mandatory information is marked with an asterisk (*).

Printable PDF Version of Form (Optional)

(if using PDF version of form):
Please email completed form to info@wordpress-786993-3913004.cloudwaysapps.com

Please enable JavaScript in your browser to complete this form.

YOUR INFORMATION

First Name *

Last Name *

Date of Birth *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Mobile Phone: *

Alternate Phone:

Occupation *

Employer *

Are You Hispanic or Latino? *

Race (check all that apply) *

White/Caucasian
Black/African American
American Indian/ Alaska Native
Native Hawaiian/ Other Pacific Islander
Asian

_____________________________

EMERGENCY CONTACT

Name *

Relationship to Self *

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

_____________________________

DETAILS ABOUT YOUR RIDE

WILL ANYONE BE TRAVELING WITH YOU (Y/N)? Please read note below this prompt: *

Important Note - Rides For Good can Only transport passengers Age 18 and over, we currently cannot transport minors. Each passenger traveling with you must have a Passenger Waiver Form signed and on file in our office before a ride can be scheduled (form will be included with your registration packet).

DO YOU HAVE ANY NEEDS A DRIVER SHOULD KNOW ABOUT? *

(Ex. Limited vision, walker use, need assistance walking, etc.)

DO YOU SPEAK/ UNDERSTAND ENGLISH (Y/N)? *

If no, which language?

Name of English speaking contact *

Mobile Phone Number of English Speaking Contact *

How did you hear about Rides for Good? *

Are you a Veteran (Y/N)? *

_____________________________

FOR WHAT PURPOSE(S) DO YOU ENVISION USING RIDES FOR GOOD? *

Food/Groceries
Pharmacy
Faith Activity
Mental Health Therapy
Legal Aid
Workforce Training
Class
Job Training or Interview
Medical/Dental
Social Services
Other (please specify below)

Check all that apply.

If Other, specify here:

If you were referred by a local organization/agency - Please let us know which one! *

If none, please write none or N/A

Consent to Passenger Screening *

By checking this box, I certify that I have not been convicted of any violent, sexual, theft, or felony offenses and do not have any pending cases related to violent, sexual, theft, or felony offenses. I understand that The Safe Ride Foundation reserves the right to review publicly available Maryland Court record information for potential passengers and may possibly deny use of the program to any individual based on their criminal history, including currently pending cases, at its sole discretion.

_____________________________

122 E. Patrick St, #114, Frederick, MD

(240) 657-3090

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about us

Rides For Good is being supported in part by federal award number SLFRP1623, awarded to Frederick County, Maryland by the U.S. Department of the Treasury.

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Passenger Registration

Online Passenger Registration Form

YOUR INFORMATION

_____________________________

EMERGENCY CONTACT

_____________________________

DETAILS ABOUT YOUR RIDE

_____________________________

_____________________________

about us

Rides for Good is a Program of:

Keep up to date with the program join the mailing list!

Keep up to date with the program
join the mailing list!