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2. R-Transit Group Trip Request
4. All group trip requests should be submitted 10 business days in advance.
6. Today's Date*
   Today's Date
7. Facility Name
9. Trip Coordinator*
10. Trip Coordinator Phone #*
12. Trip Coordinator E-mail Address*
13. Secondary Phone #
17. TRIP DETAILS
19. R-Transit service area includes the Cities of Richmond, El Cerrito, San Pablo, North Richmond, El Sobrante, and Kensington, as well as unincorporated communities of East Richmond Heights, Bayview-Montalvin, Hasford Heights, Rollingwood, and Tara Hills. Service is available as far as North as Doctor's Hospital in Pinole and as far South as El Cerrito Plaza in El Cerrito.
21. Group Trip Date*
    Group Trip Date
22. Pick up Time
    Pick up Time
    First available pick up is 9:30 am
23. Return Time
    Return Time
    Last return time available is 3 pm
25. Pick Up Address*
27. City*
28. State*
29. Zip
31. Drop off Address*
33. City*
34. State*
35. Zip*
39. REGISTERED CLIENT INFORMATION
41. For capacity reasons, select the mobility type of each passenger and if he/she will be bringing any mobility aids on board.
    Note: Wheelchair Size is measured by the width of the wheelchair. The width should include the outside of the tires.
43. R-Transit Client Name
44. Mobility Type
    -- Select One --AmbulatoryWheelchairPower Scooter
45. Mobility Aids
    -- Select One --NoneCaneWalkerCrutches
47. Wheelchair Type*
    -- Select One --Power WheelchairManual Wheelchair
48. Wheelchair Size (Width)*
    -- Select One --Small: 25" or lessStandard: 26"Large: 27" - 29"Extra Large: 30" - 33"
49. Wheelchair Transfer*
    -- Select One --YesNo
51. R-Transit Client Name
52. Mobility Type
    -- Select One --AmbulatoryWheelchairPower Scooter
53. Mobility Aids
    -- Select One --NoneCaneWalkerCrutches
55. Wheelchair Type*
    -- Select One --Power WheelchairManual Wheelchair
56. Wheelchair Size (Width)*
    -- Select One --Small: 25" or belowStandard: 26"Large: 27" - 29"Extra Large: 30" - 33"
57. Wheelchair Transfer*
    -- Select One --YesNo
59. R-Transit Client Name
60. Mobility Type
    -- Select One --AmbulatoryWheelchairPower Scooter
61. Mobility Aids
    -- Select One --NoneCaneWalkerCrutches
63. Wheelchair Type*
    -- Select One --Power WheelchairManual Wheelchair
64. Wheelchair Size (Width)*
    -- Select One --Small: 25" or belowStandard: 26"Large: 27" - 29"Extra Large: 30" - 33"
65. Wheelchair Transfer*
    -- Select One --YesNo
67. R-Transit Client Name
68. Mobility Type
    -- Select One --AmbulatoryWheelchairPower Scooter
69. Mobility Aids
    -- Select One --NoneCaneWalkerCrutches
71. Wheelchair Type*
    -- Select One --Power WheelchairManual Wheelchair
72. Wheelchair Size (Width)*
    -- Select One --Small: 25" or belowStandard: 26"Large: 27" - 29"Extra Large: 30" - 33"
73. Wheelchair Transfer*
    -- Select One --YesNo
75. R-Transit Client Name
76. Mobility Type
    -- Select One --AmbulatoryWheelchairPower Scooter
77. Mobility Aids
    -- Select One --NoneCaneWalkerCrutches
79. Wheelchair Type*
    -- Select One --Power WheelchairManual Wheelchair
80. Wheelchair Size (Width)*
    -- Select One --Small: 25" or belowStandard: 26"Large: 27" - 29"Extra Large: 30" - 33"
81. Wheelchair Transfer*
    -- Select One --YesNo
83. R-Transit Client Name
84. Mobility Type
    -- Select One --AmbulatoryWheelchairPower Scooter
85. Mobility Aids
    -- Select One --NoneCaneWalkerCrutches
87. Wheelchair Type*
    -- Select One --Power WheelchairManual Wheelchair
88. Wheelchair Size (Width)*
    -- Select One --Small: 25" or belowStandard: 26"Large: 27" - 29"Extra Large: 30" - 33"
89. Wheelchair Transfer*
    -- Select One --YesNo
91. R-Transit Client Name
92. Mobility Type
    -- Select One --AmbulatoryWheelchairPower Scooter
93. Mobility Aids
    -- Select One --NoneCaneWalkerCrutches
95. Wheelchair Type*
    -- Select One --Power WheelchairManual Wheelchair
96. Wheelchair Size (Width)*
    -- Select One --Small: 25" or belowStandard: 26"Large: 27" - 29"Extra Large: 30" -33"
97. Wheelchair Transfer*
    -- Select One --YesNo
99. R-Transit Client Name
100. Mobility Type
     -- Select One --AmbulatoryWheelchairPower Scooter
101. Mobility Aids
     -- Select One --NoneCaneWalkerCrutches
103. Wheelchair Type*
     -- Select One --Power WheelchairManual Wheelchair
104. Wheelchair Size (Width)*
     -- Select One --Small: 25" or belowStandard: 26"Large: 27" - 29"Extra Large: 30" - 33"
105. Wheelchair Transfer*
     -- Select One --YesNo
107. R-Transit Client Name
108. Mobility Type
     -- Select One --AmbulatoryWheelchairPower Scooter
109. Mobility Aids
     -- Select One --NoneCaneWalkerCrutches
111. Wheelchair Type*
     -- Select One --Power WheelchairManual Wheelchair
112. Wheelchair Size (Width)*
     -- Select One --Small: 25" or belowStandard: 26"Large: 27" - 29"Extra Large: 30" - 33"
113. Wheelchair Transfer*
     -- Select One --YesNo
115. R-Transit Client Name
116. Mobility Type
     -- Select One --AmbulatoryWheelchairPower Scooter
117. Mobility Aids
     -- Select One --NoneCaneWalkerCrutches
119. Wheelchair Type*
     -- Select One --Power WheelchairManual Wheelchair
120. Wheelchair Size (Width)*
     -- Select One --Small: 25" or belowStandard: 26"Large: 27" - 29"Extra Large: 30" - 33"
121. Wheelchair Transfer*
     -- Select One --YesNo
123. For additional passengers, please fill out another group trip request form.
127. ATTENDANT/GUEST INFORMATION
129. One (1) attendant is allowed to ride free with up to six paying registered passengers. Two (2) attendants are allowed to ride free with seven or more paying registered passengers. Additional attendants & guests may accompany passengers if space is available and will be required to pay individual fares.
131. Attendant Name*
132. Attendant Phone Number*
134. Attendant Name
135. Attendant Phone Number
137. Additional Attendants/Guests
     -- Select One --Additonal attendantAdd Guest
138. Attendant Name*
     Additional attendants are subject to pay individual fares.
139. Attendant Phone Number*
141. Guest Name
     All guests are subject to pay individual fares.
142. Guest Name
143. Guest Name
147. An R-Transit scheduler will contact the trip coordinator to confirm the trip within 3-5 business days of receiving the trip request. To cancel the trip, the trip coordinator must contact R-Transit within 3 business days of the planned trip. All cancellations after 3 business days will be subject to full fare. A new group trip request form must be filled out if you wish to modify the passenger list. All modifications must be made 3 business days prior to scheduled trip.
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149. 1. Receive an email copy of this form.
150. Email address

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151. Submit

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