Share A Fare Application

* * For questions about Share A Fare in Kansas City, Missouri, please click http://www.ridekc.org/ or call 816-842-9070.

Certifying authority:

Please complete the below online application form for the Share A Fare program for your patient/client/consumer. Alternatively, download .pdf version of application.

If providing a post office box as a primary mailing address, we also require, for geographical purposes, a physical street address of residency. Without this information, we will be unable to process your application.

APPLICANT'S INFORMATION

Applicant's first and last name *

Date of Birth *

Gender *

Primary Phone *

Alternate Phone

Street Address: MUST be in our service area in counties of Douglas, Sarpy, Cass, Dodge, Lancaster, and Washington in Nebraska, as well as Pottawattamie in Western Iowa. *

Choose your Zip/City combination *

County of Residence *

Full Mailing Address (if different from above):

Email Address *

Confirm Email Address *

Are you a current or former member of the military? *

Race(s) with which you identify: *

How did you hear about Share A Fare?

CERTIFYING AGENT'S INFORMATION

Does applicant have low vision or legal blindness? *

Medical Cause of Blindness or Visual Impairment: *

Additional disabilities/health conditions the applicant experiences. (optional)

Certification of Eligibility *

Certification of applicant in program service area *

Certifying Agent's name: *

Title: *

Certifying Agent's Phone: *

Certifying Agent's address: *

Certifying Agent's Email Address *certifying agent’s email address

Confirm Email Address *

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