Name *

First Name

Last Name

Have You Applied AND Been Accepted Into This Program? *

If you haven't already applied and been accepted into this program your trip request will be automatically denied. You must contact our office to apply.

Yes

No

Preferred Contact Number *

(###)

###

####

Preferred Method of Contact *

Call

Text

Email

Does the Trip Meet Eligibility Requirements? *

Addiction treatment; healthcare appointment; court ordered service; or family-oriented, direct service community events (example: Court, court-ordered inpatient/outpatient treatments, Celebrate Recovery, DCS appointment, support group or medical needs, health fairs, job fairs, free school supply events, etc)

Yes

No

Date of Trip *

Must be Monday-Friday.

MM

DD

YYYY

Time of Pick Up *

The earliest you can schedule a pick up is 8:30 am.

Hour

Minute

Second

AM PM

Estimated Time to Be Picked Back Up From Appointment *

Scheduled time must allow for you to be dropped off at your final drop off location no later than 5:00 pm with the exception of Celebrate Recovery Community programs.

Hour

Minute

Second

AM PM

Pick Up Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Destination Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Is Final Drop Off Address Different From Beginning Pick Up Location? *

Yes

No

Final Drop Off Location Address if Different From Beginning Pick Up Location?

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Will Anyone Be Accompanying You? *

Yes

No

Are They a Minor? *

It is your responsibility to provide a car seat/booster if one is required by law.

Yes

No

Have They Ever Been Convicted of : *

Murder/Attempted Murder

Assault

Robbery

Car Jacking

Domestic Violence

None

Emergency Contact Person *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####