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2. Rider Information
4. Youth First Name
5. Youth Last Name
7. Date of Birth
   Date of Birth
8. Age
10. Address
12. City
13. State
14. Zip Code
16. Phone Number
18. Email Address
20. Parent / Guardian Information
22. First Name
23. Last Name
25. Relationship
27. Phone Number
28. Alt Phone Number
30. Email Address
32. Emergency Contact Information

    (Must be someone other than the parent/guardian listed above)

34. First Name
35. Last Name
37. Relationship
39. Phone Number
41. Acknowledgment of Expectations for Independent Travel

    1. My child will be traveling without direct adult supervision during transport.
       
       

    2. My child must follow all Community Connector rules, including respectful conduct toward drivers and passengers.
       
       

    3. My child must be able to enter and exit the vehicle independently and manage their own belongings.
       
       

    4. My child must have a way to contact me or another emergency contact during travel.
       
       

    The Community Connector reserves the right to deny service to any youth who does not follow these rules or whose permission form is not on file.

43. Consent & Release

    I, the undersigned parent or legal guardian, give permission for my child named above to use the Winchendon Community Connector’s pre-booked microtransit services independently. I acknowledge that my child will be riding without direct adult supervision and accept full responsibility for their travel arrangements.

    I release and hold harmless The Town of Winchendon, their staff, drivers, and affiliates from any liability for injury, loss, or damage arising from my child’s independent travel, except as provided by law.

45. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
47. Electronic Signature
49. Date
    Date
51. Office Use Only

    
     ☐ Approved for Independent Microtransit Use
     ☐ Not Approved – Reason: _______________________________________

    Approved by: ___________________________ Date: _______________

Leave This Blank:


53. 1. Receive an email copy of this form.
54. Email address

    This field is not part of the form submission.

55. Submit

* indicates a required field