Campbell, Crook, Johnson, Sheridan, and Weston Counties

The current mobility specialist for Campbell, Crook, Johnson, Sheridan, and Weston Counties is Erwin Reitsma and all referrals made on this page will be sent directly to Erwin. Please fill in the following information to make a referral to the Transportation Check Program for someone living in one of these counties.

referral

* Indicates required field

Name of the Person Making the Referral *

Organization/Title *

Phone Number for Person Making Referral *

Email Address for Person Making Referral *

Referral Information

Name *

First

Last

Date of Birth *

Phone Number *

Address *

City *

Zip Code *

Type of Referral *

The person being referred wants more information on transportation options. The person being referred wants to be on the Transportation Check Program. The person being referred is in need of travel training to utilize public transportation.

Main Form of Transportation Currently *

Public Transportation on a Fixed Route Bus Public Transportation on a Para Transit or Curb to Curb Service Private Transportation by a Friend or Relative Has No Transportation Options Currently

Disabilities that prevent driving *

Other Comments *

Submit

referral

​Referral Information

Referral Information