Application for Transportation Services

 

There are several ways to apply for transportation services. You may fill out the form below and a Wheels of Hope representative will contact you to complete the application. You can also download a PDF version of the application to return to Wheels of Hope by e-mail or regular mail. You can call our offices at any time for further assistance.

Wheels of Hope respects your privacy and will keep all customer information confidential. The information you provide allows us to provide better service to our customers, and helps us better understand the circumstances that customers face when they apply to use Wheels of Hope for rides.

(Please complete one form per rider)

 
Rider's Name *
Rider's Name
Home Phone
Home Phone
Cell Phone
Cell Phone
Person completing this form: *
Type of Membership
Address
Address
What form of communication do you prefer?
what form of communication do you prefer?
How did you hear about Wheels of Hope?
Name and relationship of person who made referral

Personal Transportation Account Agreement

1.    You will maintain a balance in your account sufficient to cover your monthly rides;

2.    Your membership dues will be automatically debited on the anniversary of your membership;

3.    If you have an unpaid balance greater than $200 for longer than 60 days, your account will be paused until you have deposited sufficient funds to again achieve a positive balance;

4.    If there is no activity in your account for one year and we have made three documented unsuccessful attempts to reach you, you agree that the balance in your account will become a charitable gift to Wheels of Hope.

5.    Your contacts may receive a limited number of mailings (via regular mail or e-mail) for the Wheels of Hope fundraising events/campaigns, as well as up to four quarterly Wheels of Hope Newsletters. Their names will not be shared with any other party or organization.

A personal Wheels of Hope transportation account is like a personal bank account. It is debited whenever you take a Wheels of Hope ride, and when you make a payment to Wheels of Hope, it is like making a deposit into your account. At the end of each month, you receive a statement that details your rides and any other account activity. Wheels of Hope is a charitable nonprofit service supported by your fares and voluntary local community support. Because fares cover only half the true cost of rides, the Wheels of Hope affiliate may include family members and any others you have listed as contacts in its fundraising campaigns.

Participation in these campaigns is voluntary. A contact’s decision not to participate will not affect the quality of your service or your eligibility to use Wheels of Hope for rides.

Informed Consent

Wheels of Hope is a non-profit, community-based organization providing dignified, consumer-oriented transportation for people with visual impairments.

In the spirit of this public/private effort, to continue the development and analysis that will allow Wheels of Hope to better understand the mobility needs of older Americans, their families and their communities, and to continuously improve the quality and sustainability of the service, we routinely collect data about riders and the rides we deliver. The identity of our riders is kept entirely confidential in all reports we use for these purposes.