Dial-A-Ride Membership Registration

A Dial-A-Ride Membership card is required and is renewed annually on January 1st. The cost is $75.00.

Please make check or money order payable to "Senior Citizens Bus Committee".

Your Application and Remittance (check or money order) may be brought or mailed to the Dial-A-Ride Office, 299 Elm Street (Enfield Senior Center), Enfield, CT 06082. Please include a self-address stamped envelope if you want your ticket mailed to you.

NAME___________________________________

ADDRESS________________________________

_______________________________________ ZIP CODE_______________

Telephone No.___________________________ Date of Birth _____________

Wheelchair used: Yes____ No ____

Special Assistance required: Yes____ No ____

Signature__________________________________ Date __________________

EMERGENCY CONTACT PERSON:

Name_______________________________________________________

Address_____________________________________________________

____________________________________________________________

Relationship__________________________________

Phone #'s Home ________________ Work ________________________

Doctor ____________________________________________________