Primary Household

Parent/Guardian Name:

Address:

City:

State:

Zip:

Phone:

E-mail Address:

Secondary Household

Parent Name:

Address:

City:

State:

Zip:

Phone:

E-mail Address:

Child's Information

Name:

Date of Birth:

Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950

Emergency Contact

Name

Relationship

Address

City

Home Phone

Work Phone

Cell Phone

Schedule Trip(s)

Pickup Start Date

Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2017 2018

Pickup From Name & Address:

Take to Name & Address:

School/Daycare Start Time

Trip Method:

One Way Round Trip

Trip Choice:

Year Pass Semester Pass 20 trips

Trip Qty:

Mon-Fri 4-day/week 3-day/week 2-day/week

Trip Days (if not Mon-Fri):

Monday Tuesday Wednesday Thursday Friday

Pickup From Name & Address:

Take to Name & Address:

School/Daycare End Time

Quantity (1 ticket = one-way trip) :

1 2 3 4 5 6 7 8 9 10 20 30 40 (Each Trip is $2.00)

Person Responsible for Payment

I agree to allow Prairie Hills Transit to provide transportation for my child. I will notify PrairieTransit as soon as possible of any scheduling changes or cancellations. If adequate verbal or electronic cancellation notice of one hour is not given nor a message left on voice mail, e-mail or by using online scheduler, you will be charged a $2.50 fee.

Parent/Guardian Name:

Address:

City:

State:

Zip:

Phone:

E-mail Address:

Secondary Household

Parent Name:

Address:

City:

State:

Zip:

Phone:

E-mail Address:

Date of Birth:

Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950

Veteran Status:

Yes No

Emergency Contact

Name

Relationship

Address

City

Home Phone

Work Phone

Cell Phone

Pick Up Location & Time

Pickup times for in-town service are 30 minutes before an appointment.
Pickup times will be 45 minutes if assistance is needed or outside city limits.

Pickup Date*

Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2017 2018

Appointment time

AM PM

Pick Up Location Name *

Street Address *

Suite/Apt/Unit #

City *

Zip *

Phone Number

Is this your home address? *

Yes No

Is this an Assisted Living location?

Yes No

Ambulatory Non-Ambulatory

Additional information that may be needed, for example, certain door at either pick-up and/or drop off location.

Drop Off Location

Drop Off Location Name *

Street Address *

Suite/Apt/Unit #

City *

Zip *

Phone Number

Return Trip Information

Is a return trip needed? *

Yes No

If yes, please enter

Return Trip Date*

Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2017 2018

Return Trip Time*

AM PM Will Call when finished

Additional information that may be needed, for example, certain door at drop off location.

Return Pick up Address

Location Name

Street Address

Suite/Apt/Unit #

City

Zip

Phone Number

Trip Details

Please select any mobility device(s) that traveler(s) will use   

Escort (a person can ride with the customer for assistance only – no charge)

Special Instructions
500 characters max.

Quantity (1 ticket = one-way trip) :

Person Responsible for Payment

Pick Up Location & Time

Pickup times for in-town service are 30 minutes before an appointment.
Pickup times will be 45 minutes if assistance is needed or outside city limits.

Parent/Guardian Name:

Address:

City:

State:

Zip:

Phone:

E-mail Address:

Secondary Household

Parent Name:

Address:

City:

State:

Zip:

Phone:

E-mail Address:

Date of Birth:

Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950

Veteran Status:

Yes No

Emergency Contact

Name

Relationship

Address

City

Home Phone

Work Phone

Cell Phone

Pickup Date*

Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2017 2018

Appointment time

AM PM

Pick Up Location Name *

Street Address *

Suite/Apt/Unit #

City *

Rapid City Belle Fourche Deadwood Central City Custer Edgemont Lead Hot Springs Newell Nisland Spearfish St. Onge Sturgis Vale Whitewood

Zip *

Phone Number

Is this your home address? *

Yes No

Is this an Assisted Living location?

Yes No

Additional information that may be needed, for example, certain door at either pick-up and/or drop off location.

Drop Off Location

Drop Off Location Name *

Street Address *

Suite/Apt/Unit #

City *

Please choose your pickup city above first Belle Fourche Deadwood Central City Custer Edgemont Lead Hot Springs Newell Nisland Spearfish St. Onge Sturgis Vale Whitewood

Zip *

Phone Number

Return Trip Information

Is a return trip needed? *

Yes No

If yes, please enter

Return Trip Date*

Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2017 2018

Return Trip Time*

AM PM

Additional information that may be needed, for example, certain door at drop off location.

Return Pick up Address

Location Name

Street Address

Suite/Apt/Unit #

City

Belle Fourche Deadwood Central City Custer Edgemont Lead Hot Springs Newell Nisland Spearfish St. Onge Sturgis Vale Whitewood Please select an item.

Zip

Phone Number

Trip Details

Please select any mobility device(s) that traveler(s) will use   

Escort (a person can ride with the customer for assistance only – no charge)

Special Instructions
500 characters max.

Quantity:

1 2 3 4 5 6 7 8 9 10 20 30 40

Person Responsible for Payment