Rides for Members Questionnaire

Use this form to gather necessary information to best serve members who are unable to drive.

Member's Name Member's Name First Last
Member's Telephone Member's Telephone - ### - ### ####
How many stops do you anticipate?

How many stops do you anticipate? 1 2 3 4 5+

Ideally want same drive but if time needed requires more than one person can give may be necessary.
How much time is needed to accomplish what you want?
What type of business are you going to?

What type of business are you going to? Doctor Grocery Store Pharmacy Postal Service Shop / Mall Other
What is the address? What is the address?
Street Address Address Line 2 City State / Province / Region Postal / Zip Code
What time is your appointment? What time is your appointment? : HH MM AM/PM
For Multiple Locations: List the location names and addresses; include appointment times.

Examples:

CVS Pharmacy
4600 Oleander Drive

Dr. Delaney Smith
100 Main Street
10:30 am
What time would you like to be picked up? What time would you like to be picked up? : HH MM AM/PM
Are you comfortable if the pickup and return drivers are different people?

Are you comfortable if the pickup and return drivers are different people? Yes No

Ideally want same drive but if time needed requires more than one person can give may be necessary.
Are you comfortable if the driver drops you off, leaves you, then returns at a later time?

Are you comfortable if the driver drops you off, leaves you, then returns at a later time? Yes No

Ideally want same drive but if time needed requires more than one person can give may be necessary.
What type of vehicle are you able to get into?

What type of vehicle are you able to get into? Any Type Low Car (small or large) Low but roomy Other
Are you comfortable listening to spiritual music or talking?

Are you comfortable listening to spiritual music or talking? Yes No Notes

Ideally want same drive but if time needed requires more than one person can give may be necessary.
Related Notes