🚗 Online Transportation Request Form 1📃 Contact Information2📅 Select Ride Date(s)3🗺️ Address Details4ℹ️ Other5📝 Review Request To make a transportation request please complete the form below.Are you a current client?(Required)Please make a selectionYes I am a current clientNo, I am not a current clientI am making this request on behalf of an existing client (Please select and enter your contact info below)I am making this request for a new client (Please select and enter your contact info below)Please note that new clients are required to undergo an intake interview to determine their eligibility, as well as to review the role and responsibilities of the client and the agency providing the service. This must be completed before service begins.Your Contact InformationName(Required) First Last Telephone Number(Required)Email Referrer InformationReferrer Name(Required) First Last Relationship to Cliente. g. son / daughter or name of referring organizationReferrer Telephone Number(Required)Referrer Email Client InformationClient Name(Required) First Last Client Telephone(Required)Client Email Please click Add Ride Date/Time below to select the date of your requested ride. Requests must be submitted a minimum of 3 business days prior to the appointment date. You can book a ride up to 4 months in advance. Dates in which service is not available are greyed out.📅 Choose Your Ride Date(s) Date of Ride Appointment Time Arrival Time Return Pick-up Time Actions Edit Delete Please add one or more Ride Dates & Times... Add Ride Date/Time Maximum number of ride dates/times reached. 🗺️ Please Confirm Address DetailsMobility Needs(Required)NoneElectric Wheel ChairManual Wheel ChairRampOtherWill anyone be accompanying you?(Required)None1 Person2 PersonsOne-Way or Round Trip?(Required)One-Way TripRound TripTransportation Type(Required)To Destinations Within City of Ottawa LimitsTo Destinations Outside City of Ottawa LimitsPickup Address(Required) Street Address Address Line 2 City Postal Code Drop-off Address(Required) Street Address Address Line 2 City Postal Code Message: (Please note your required arrival time at your appointment if it is earlier than the appointment time, and any additional mobility or accompaniment needs in the message box below) {all_fields}PLEASE CHECK THE BOX BELOW TO CONFIRM THE FOLLOWING(Required) I have reviewed the privacy consent policy (Click here to review our policy)
