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Dial-A-Ride Form

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Please correct the field(s) marked in red below:

Proof of disability OR age (65+) is required. Please mail to 633 E. Broadway, Room 300, Glendale, CA 91206 or fax documents to the City of Glendale at 818-240-7239.

You may also email to DialARide@glendaleca.gov.

Date of Birth:

If you were born before 1964, please type in your date of birth, including the year.
 *
Gender:
Gender:
Title:
Title:
First Name:
 *
Last Name:
 *
Home Phone:
 *
Cell Phone:
Email Address:
Current Address:
Apt. or Unit No.:
City:
City:
Zip Code:
Type of Residence:
Type of Residence:
Field Check (Do you live on a steep hill?):
Field Check (Do you live on a steep hill?):
Where do you travel the most?

Destination #1
Address:
Phone Number:

Destination #2
Address:
Phone Number:

Destination #3
Address:
Phone Number:
Do you require an attendant?
Do you require an attendant?
Nature of Disability:
Language:
Language:
If you use a wheelchair, is it:
If you use a wheelchair, is it:
Do you use a:
Do you use a:
Hard of Hearing:
Hard of Hearing:
Legally Blind:
Legally Blind:
Additional Comments:
In case of emergency notify:
Contact:
Title (Mr./Mrs./Ms.):
Name:
Phone:
Relationship:
Additional Contact Information:
Contact:
Title (Mr./Mrs./Ms.):
Name:
Phone:
Relationship:
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