CHATS - Community & Home Assistance to SeniorsDrive Request Form

Name*
First Last
Email*
Phone*
Street Address*
City*
Primary Contact Name (if different than the client)
Primary Contact Phone Number (if different than the client)
Date of Ride*
Month
Day
Year
Appointment Time*

: Hours

Minutes

AM/PM

(Please only note appointment time – Pick up time will be determined by the driver)
Appointment Length*
(Driver cannot wait if appointment runs late. It is recommended that the length be set longer than anticipated)
Drive Purpose*
Destination Address (including suite number if applicable)*
Destination City*
Destination Contact Name or Department*
Destination Phone Number*
Will you have a walker?*
- Yes
- No
Will you have a wheelchair?*
- Yes
- No
Do you need to bring an escort?*
- Yes
- No
An escort may travel with you only if you are not physically or cognitively able to travel alone
Special Instructions
CAPTCHA