COA PEERS Participant Program

Full Legal Name*

First NameLast Name

E-mail*

example@example.com

Phone Number

Area CodePhone Number

Date of birth

Date

address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Why are you in need of a PEER?

Are you a Veteran, Active Duty, Retired, or Spouse/Depdent of a Veteran, Older Adult, or have a disability?

COA PEERS can make a weekly check in phone call to you. Please choose the best time to receieve a phone call

What time is your procedure?

Please choose the best time slot which includes appointment and drive time you're in need of a COA PEERS (We need a minimum 2 week notice, if any request less than 2 weeks needs to be approved by our Program Manager.

What type of procedure, Infusion, or special need appointment do you have?

What's the contact name, number & address of clinic your appointment is at?

How many hours of service are you needing? (please read Update Regarding donation/tips for services)

5 hours or less5 hours but no more than 6 hours6 hours but no more than 8 hours5 hours plus 2 hours (for in home assistiance)

Do you have any of the following diagnosis?

Do you use any assistive devices for mobility?

An additional option you have through the COA PEERS Program is you can request your PEER attend an outside activity or volunteer event or both if you're needing assistance or needing to get out. which do you prefer?

Do you prefer your PEERS participant to be female, male, or no preference

Have you ever been convicted of a crime?

What's your barrier for needing transportation?

do you consent to a photo for use on our social media sites?

UPDATE:Regarding Tips/Donations for COA PEER Services starting Jan 2024

COA PEERS has updated our free services due to inflation prices across the nation, limited volunteer pool, gas, time, and vehicle maintenance. We now ask for a minimum of $30 dollars donation/driver tip for COA PEER services of 5 hours or less. This will include pick up from your home, transportation to you sedative procedure or special needs appointment, wait in clinic or nearby during your procedure, pick up from hospital/clinic and take you home or if you need to pick up food or make a quick stop before taking you home and ensuring you're safe inside. If more than 5 hours is needed for our services than an additional $10 per hour (max additional hours is 5 hrs) donation is requested. We will need the donation 24 hours of your appointment date. If you're requesting a COA PEER remain with you in your home for up to 2hrs after your procedure than we're requesting a $80 donation and additonal paperwork be filled out. Donation is due 24 hours before date of procedure via check (a receipt will be provided) or ZELLE, Paypal, or VENMO. Please feel free to reach out to the coordinator of COA PEERS with any concerns on this matter Leroy Martinez 210-445-0697.

I agree as a participant of the COA PEERS Program that it's completely voluntary, we're not associated with the veterans healthcare, and to be understanding and kind to PEERS.They are volunteering their time. I agree to not hold Circle of Arms(COA) or a COA PEER responsible or liable financially, Physically, or mentally of any not at fault accidents via motor vehicle or while not in the motor vehicle. I agree to report immediately to COA director any miscommunication or incidents involving a COA PEER.

I plan to pay donation by

PayPal Checkout belowVenmo CheckoutCheckCash

COA PEERS TRANSPORT/escort Service

USDDONATION AMOUNT YOU"RE GIVING, IF YOU NEED A DONATION RECIEPT PLEASE NOTIFY US. Leave blank if paying in cash

Payment Methods

Please click one of the PayPal options to complete payment and submit the form.

Register for COA PEER Program (participant)