Health Care Ride Request Form

This form is only for requesting rides to health care appointments.
We will contact you IF we can provide the ride you request.

Name of Rider

Email or Phone

If the above number is a cell phone, would you like to receive text message confirmation? (required)

Yes

Not a cell phone

Has the rider ever had a ride with Project CAR?(required)

Yes

Not Sure

If the rider has never had a ride with Project CAR, please provide home address.

Date of Appointment (YYYY-MM-DD)

Check-In Time for Appointment

Approximate Time for Going Home

Location of Appointment (Clinic Name/Address)

If this is a recurring ride to the same location, please let us know the times/dates below.

If you are making this request for someone else, please indicate your name and contact information below.