Dial-A-Ride Online Application

2. Application Requirements
   Dial-A-Ride service is for Temple City residents living within City limits, 69 years and over, or under 60 with a physical, psychological or developmental disability certified by a physician. Applicants under 60 must also submit a Physicians Verification form. Applications submitted online must include a copy of CA Driver's License or CA ID for processing. If your photo ID does not list your current address, please include a copy of a current utility bill.

   Dial-A-Ride service is for Temple City residents living within City limits, 69 years and over, or under 60 with a physical, psychological or developmental disability certified by a physician. Applicants under 60 must also submit a Physicians Verification form. Applications submitted online must include a copy of CA Driver's License or CA ID for processing. If your photo ID does not list your current address, please include a copy of a current utility bill.

4. First Name

5. Last Name

6. Telephone

8. Address1

10. City

11. State

12. Zip

14. Do you use a:

    1. Walker
    2. Cane
    3. Wheelchair
    4. Other

    Check all that apply.

15. Do you require an escort to accompany you on your rides?

    1. Yes
    2. No

16. Escorts
    Dial-A-Ride members are allowed one adult escort at time of transport. A 50 cent fee is required to all passengers, including escorts. Please notify dispatch at the time of reservation if an escort is to accompany you.

    Dial-A-Ride members are allowed one adult escort at time of transport. A 50 cent fee is required to all passengers, including escorts. Please notify dispatch at the time of reservation if an escort is to accompany you.

20. In the event of an emergency, please notify the following relative:

22. First Name:

23. Last Name:

24. Telephone:

26. Address:

27. City:

28. State:

32. In the event of an emergency, please notify the following friend/neighbor:

34. First Name:

35. Last Name:

36. Telephone:

38. Address:

39. City:

40. State:

44. In the event of an emergency, please notify my doctor:

46. First Name:

47. Last Name:

48. Telephone:

50. Address:

51. City:

52. State:

56. Proof of Address:*

    Copy of CA Driver's License or CA ID. If address is not current, please separately attach a copy of a recent utility bill.

57. Utility Bill

    Copy of a recent utility bill is required if your CA Driver's License or ID does not match your current address.

58. Physicians Verification Form:

    Applicants under 60 must submit a completed Physicians Verification Form.

62. Digital Signature:

63. Date:

Leave This Blank:


65. 1. Receive an email copy of this form.
66. Email address

    This field is not part of the form submission.

67. Submit Submit and Print

* indicates a required field