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Rider Intake Form

this is for an On-Demand (Uber) Ride Program

Go Geer serves a very specific geographic area that connects parts of Torrington and parts of Winsted, centered around the downtown areas and where most medical providers and senior housing is located. We have attempted to be sure to include most residential areas, especially where low income congregate senior housing is located and the majority of healthcare facilities. This may change as we operate the program and learn more.

To view the map of the service area go to our website: www.geercares.org/transportation

Riders must complete this form and be accepted into the program

before being able to request a ride. This can take 24-48 business hours to be processed.

Rides can only START AND FINISH in the service area, which includes most areas of Torrington and Winsted.

Eligibility is currently limited to individuals over the age of 60 and/or disabled.

Details can be found on our website www.geercares.org/transportation.

For more information or questions, please call (860) 453-4800.

First Name*

Last Name*

Address, line 1

City

State

Zip Code

A cell phone number is required if you will want to book your own rides through the App.

Cell Phone

Best number to reach you at, IF DIFFERENT from your cell phone number

Main Phone

Email address is required to complete this form, if you don't have an email address - please call to apply.

Email Address*

Date of Birth*

Gender*

Preferred Language

Referred by: individual name and company

Referred by: phone number

We will call you to review your application and let you know if you qualify.

SUBMIT