2. Complete this form to request Scheduled Rides only *

   Make trip requests at least two business days before your trip date, by noon, up to one month in advance. Trip requests for Monday must be submitted by noon on Thursday. Trip requests for Tuesday must be submitted by noon on Friday.

   Once your trip request has been submitted you will receive a confirmation email that it has been received by the Scheduling Office.

   A scheduler will then notify you by phone or email whether or not, based on availability, your trip request can be scheduled. If not, you may choose to go on the waiting list and be notified the day before if space becomes available.

   If you need to follow up on a request please call the Scheduling Office at (937) 708-8322, and choose option 1.

   *Please note that this form does not work for one-way trips with multiple stops or for Flex Route Deviations. These type of requests must be called into our Scheduling Office directly.

   
   

4. General Info*

   New or Existing Passenger?

   1. New Passenger
   2. Existing Passenger
6. First Name*
   Please Include Middle Initial
7. Last Name*
   Please include if you are a Junior (Jr) or a Senior (Sr)
9. Home Address*
11. Mailing Address
    If not the same as Home Address
13. City*
14. State*
15. Zip*
17. Phone number*
18. Alternate Phone Number
19. Date of Birth*
    Date of Birth
20. Gender*

    1. Male
    2. Female
22. Email Address*
23. Confirm Email Address*
25. Please check all that apply:

    1. Veteran
    2. Elderly (65+)
    3. Disabled
    4. Low Income
    5. Child (13 and under)
26. Mobility Type*
    -- Select One --AmbulatoryCaneCrutchesDeafElectric ScooterElectric WheelchairHearing ImpairedKnee ScooterOversized Scooter Oversized WheelchairSlow/Ambulatory/needs extra timeVisually ImpairedWalkerWheelchair

    Oversized mobility devices must be verified by Greene CATS. Verification may cause trip delay.
27. Will you have a Personal Care Attendant to travel with you due to a disability?*

    Please Check One Box:

    1. Yes
    2. No
28. If yes, Attendant Mobility Type
    -- Select One --AmbulatoryCaneCrutchesDeafElectric ScooterHearing ImpairedKnee ScooterOversized ScooterOversized WheelchairSlow/Ambulatory/needs extra timeVisually ImpairedWalkerWheelchair
30. Trip Info*

    Is this Round Trip?

    1. Yes
    2. No
31. Reservation Trip Date*
    Reservation Trip Date
    Reservation can be submitted at least two business days in advance (by noon) and up to one month in advance of trip date.
32. Requested Drop Off Time*
    Requested Drop Off Time
34. Pick-up Address*

    Address you are traveling from (typically your home)

36. City*
37. State*
38. Zip*
40. Drop-off Address*

    Exact address you are traveling to including physician's name or facility name

41. Address2
43. City*
44. State*
45. Zip*
47. Trip Purpose*
    -- Select One --Agency Appointment/ProgramChild Day CareCommunity OutingCounselingDD Youth ServicesDialysisEmploymentMedical AppointmentOtherPharmacySchool/CollegeTrainingVolunteer
49. Any Special instructions for your requested trip:
    Example: you can request door-to-door assistance or assistance with carry-on items
51. Will you have a guest traveling with you?*

    1. Yes
    2. No
52. If yes, how many?
    -- Select One --12345
54. If yes, what is the Age(s) of the Guest(s)?

    1. 14+
    2. Child 13 and under
55. Guest Mobility Type
    -- Select One --Ambulatory CaneCrutchesDeafElectric ScooterElectric WheelchairHearing ImpairedKnee ScooterOversized ScooterOversized WheelchairSlow/Ambulatory/needs extra timeVisually ImpairedWalkerWheelchair
56. Will any of your guests require:*

    1. Booster
    2. Car seat
    3. Neither
58. Will you need a return ride?*

    1. Yes
    2. No
59. If yes, what time would you like to be picked up?
    If yes, what time would you like to be picked up?
61. Are you returning to same address as pick up address?*

    1. Yes
    2. No
62. If no, what address will you be returning to?
    Please include Apt, Suite, City, State and Zip code information in request.
Leave This Blank:


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

    This field is not part of the form submission.

66. Submit Submit and Print

* indicates a required field