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2. The Malibu Dial-A-Ride program provides subsidized rides to seniors (55 years of age or older) living within the City limits. Residents of any age, who are disabled from operating a motor vehicle as defined by the California Vehicle Code, are also eligible. Identification must be shown to the driver at the time of service. If proper identification is not shown, the participant will not be eligible to use the service. Submitting an application does not guarantee acceptance into the program.
4. I was previously a Dial-A-Ride member.

   1. Yes
   2. No
5. I am over the age of 55.*

   1. Yes
   2. No (if no, please contact MalibuSeniorCenter@malibucity.org)
7. I am a City of Malibu resident.*

   1. Yes
   2. No
8. Proof of Residency*

   Please upload proof of residency. Accepted items include: Driver's License, Utility Bill, Lease Agreement, or Mortgage Statement.

10. Address*
11. Date of Birth*
13. Last Name*
14. First Name*
16. Phone Number*
17. Email*
19. Emergency Contact Name*
20. Emergency Contact Phone Number*
22. I have read and agree to the Malibu Senior Center Code of Conduct.*

    1. Yes

    Code of Conduct can be found at MalibuCity.org/SeniorCenter.
24. The below signed agrees to abide by the rules, regulations and Senior Center Code of Conduct established by the City of Malibu Community Services Department.
26. Digital Signature*
27. Date *
29. RELEASE AGREEMENT

    Individuals with disabilities requiring accommodations to participate in the programs in which you are registering must inform the City of Malibu at the time of registration is submitted. Individuals needing such accommodations must document the need for such accommodations to complete the registration form or participate in the registered program. The City of Malibu, as a matter of policy and law, will administer and conduct all City Programs in such a manner that no qualified individual with a disability will be excluded from participation in, or be denied benefits of services, programs, or activities of the City. If any individual feels that he/she or a group of individuals with a disability are being discriminated against, the person(s) or group(s) are encouraged to contact the City’s ADA office by phone at 310.456.2489, or in writing to Compliance Office, 23825 STUART RANCH ROAD, MALIBU, CA 90265. I fully understand and acknowledge that my participation in the below described program (the “Program”) exposes me to risk or personal injury, death, communicable diseases, illnesses, viruses, or property damage. I hereby acknowledge that I am voluntarily participating in and fully approving my participation in this Program and agree to assume such risks. I hereby release, discharge and agree not to sue or make any claims against the City of Malibu, including its officers, employees and agents, (hereinafter the “City”) for any injury, death or damage to or loss of personal property arising out of, or in connection with, or in any way related to my participation in the Program from whatever cause, including the active or passive negligence of the City or any other participants in the program. The parties to this agreement understand that this document is not intended to release any party from any act or omission of “gross negligence,” as that term is used in applicable case law and/or statutory provision. In consideration of being permitted to participate in the Program, I hereby agree, for myself, my heirs administer, executors and assigns, that I shall indemnify, hold harmless, and defend the City from any and all claims, demands, actions or suits arising out of or in connection with my participation in the Program. I HAVE CAREFULLY READ THIS RELEASE, HOLD HARMLESS AND AGREEMENT NOT TO SUE AND FULLY UNDERSTAND ITS CONTENTS. I AM AWARE THAT IT IS A FULL RELEASE OF ALL LIABILITY AND SIGN AT MY OWN FREE WILL AND THAT THIS RELEASE IS BEING SIGNED ON MY OWN BEHALF. I further agree and acknowledge that the City does not provide accident, medical, liability, workers’ compensation insurance or any other insurance for program participants. I hereby consent to the emergency treatment as a result of accident or injury. I further agree to pay any and all costs incurred as a result of said medical treatment. I agree to carefully inspect and satisfy for myself that the vehicles are reasonably safe for their intended use in and related to the Program. I understand the City retains the right to use photos taken during activities for publicity and marketing purposes. My signature below certifies and acknowledges that I have read the Rules and Procedures on the attached sheet and that I agree to abide by all terms, rules and regulations set forth therein. When applicable, I authorize the person listed in Section 2 of this application to release to the City of Malibu, pertinent information with regard to the disability that qualifies my eligibility. The information released will be used solely to determine my eligibility for the Dial-A-Ride program.

31. Digital Signature*
32. Date *
Leave This Blank:


34. 1. Receive an email copy of this form.
35. Email address

    This field is not part of the form submission.

36. Submit

* indicates a required field