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.

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Applicant's Information

Applicant's first and last name *

Date of Birth: *

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 *

County of Residence *

Choose again your Zip/City *

Full Mailing Address (if different from above):

Email Address: *

Re-type email address *

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

Yes

Race(s) with which you identify: *

Certifying Authority's Information

This section to be completed by Doctor, Nurse, Optometrist, or Rehabilitation Counselor.

Does applicant have low vision or legal blindness? *

Low Vision: Visual Acuity 20/80 or less in the better eye with correction and/or visual field is no greater than 100 degrees

Legal Blindness: Blind in one eye and a visual acuity of 20/60 or less in other eye with correction

Medical Cause of Blindness or Visual Impairment: *

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

Certification of eligibility. *

I hereby certify that this individual does not drive and is eligible for the Share A Fare Program.

Certification of applicant in program service area. *

I acknowledge that Certifying Agents submitting false applications may be subject to legal action.

Certifying Agent's Name: *

Title: *

Certifying Agent's Phone: *

Certifying Agent's Address: *

Certifying Agent's Email Address: *

Re-type Certifying Agent's Email *

Share A Fare, Inc.

Share A Fare Application

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Share A Fare Application

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