Application to Ride Name First Last Todays Date MM slash DD slash YYYY Address City State Zip Home PhoneCell PhoneEmail Age Date of Birth MM slash DD slash YYYY Disabled Please select if rider has a disability Please briefly explain the disability Emergency Name(Required) First Last Emergency Phone(Required)Companion Rider (18yrs+) First Last Companion Rider Date of Birth MM slash DD slash YYYY Please select at least one to qualify: Senior Senior Citizen (60 yrs +) Disabled Disabled Person Low Income Low Income Companion Rider Companion Rider Service Animal Service Animal Youth Youth Race (Optional) XL Wheelchair Wheel Chair Scooter Scooter Walker Walker Wheelchair Wheel Chair Certify Name First Last Certify IncomeFamily Members Please agree to the following: Mask Agree Mask Agree Guidelines Agree Guidelines Agree ID Agree ID Agree Information Agree(Required) I hereby declare that the information provided is true and correct. I also understand that any willful dishonesty may render for refusal of this application Please upload a copy of your valid ID or Drivers LicenseAccepted file types: jpg, jpeg, gif, png, pdf, doc, docx, Max. file size: 80 MB.SignatureSigned Date
