Shuttle Bus Online Registration

Please note: This online registration is meant for people that want to sign up for a ride to Mass on Sunday, not those who are riding the shuttle bus as part of a coordinated ministry outing. Thank you!

What is today's date? REQUIRED Please fill out this field. Please enter valid data.

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Email REQUIRED Please fill out this field. Please enter an email address.

Street Address: REQUIRED Please fill out this field. Please enter valid data.

City REQUIRED Please fill out this field. Please enter valid data.

State REQUIRED Please fill out this field.

Zip REQUIRED Please fill out this field. Please enter a zip code.

Birthday REQUIRED Please fill out this field. Please enter valid data.

Gender REQUIRED Please fill out this field. Please enter valid data.

What is your marital status? REQUIRED Married Widowed Single Divorced Please fill out this field.

Do you use a wheelchair? REQUIRED Yes No Please fill out this field.

Do you use a cane? REQUIRED Yes No Please fill out this field.

Do you use a walker? REQUIRED Yes No Please fill out this field.

Do you have vision problems? REQUIRED Yes No Please fill out this field.

Do you have hearing problems? REQUIRED Yes No Please fill out this field.

Do you have any major health concerns? Please describe.

Who is your primary doctor? REQUIRED Please fill out this field. Please enter valid data.

What is your doctor's address? REQUIRED Please fill out this field. Please enter valid data.

What is your doctor's phone number? REQUIRED Please fill out this field. Please enter valid data.

What is your doctor's emergency line? REQUIRED Please fill out this field. Please enter valid data.

Who is your emergency contact? REQUIRED Please fill out this field. Please enter valid data.

What is your relationship? REQUIRED Please fill out this field. Please enter valid data.

Main Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Phone Number (cell/work) Please enter a phone number.

Assumption-Mattese

Shuttle Bus Online Registration

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Online Registration