COA Peer & TransportForm

Full Legal Name*

First NameLast Name

E-mail*

example@example.com

Phone Number

Area CodePhone Number

Date of birth

MonthDayYear

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Why are you in need of a COA PEER?

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

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?

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?

As a nonprofit from time to time we will take pictures of you and the COA PEER Volunteer to keep the community aware of our program and for future funding opportunities. do you consent to a photo for use on our social media sites?

Please read thoroughly, COA PEERS Program Service Update:

Due to rising inflation, increased fuel and vehicle maintenance costs, and a limited volunteer pool, the COA PEERS Program has updated our free service model to ensure sustainability and continued support for our community.

We are now graciously requesting a minimum donation of $40 or more for COA PEERS services lasting four (4.5) hours or less.

This donation helps cover:

*Personal door-through-door pickup from your home
*Transportation to your sedative procedure or special-needs appointment
*Escort to the front desk for check-in (when applicable)
*Volunteer wait time in the clinic or nearby during your procedure
*Pickup from the hospital or clinic after your procedure by the same volunteer
*Optional short stops (e.g., pharmacy, food pickup) — please notify your volunteer in advance
*Safe return home and confirmation that you are safely inside
If your appointment requires more than five (5) hours of service or is located outside Bexar County, an additional donation of $10 per hour (up to 3 additional hours) is requested.

A separate link will be sent to submit your donation prior to your scheduled appointment. Donations can also be made directly to your volunteer at pickup — via cash, check, Zelle, PayPal, or Venmo. (Receipts are available upon request.)

We truly appreciate your understanding and support as we continue to provide compassionate transportation and peer assistance to our veteran community.

If you have any questions or concerns, please contact our COA PEERS Administrative Clerk at 210-201-7048 or email infocoapeers1@gmail.com

I understand that participation in the COA PEERS Program is completely voluntary. Circle of Arms (COA) and the COA PEERS Program are not affiliated with the Veterans Health Administration or any of its affiliates.I agree to treat all COA PEERS volunteers with understanding and kindness, recognizing that they are donating their time to provide support.I agree to follow all instructions given by my Primary Care Manager (PCM), nurse, or medical staff before and after any sedative procedure. I understand that if I fail to follow these medical instructions, the assigned COA PEERS volunteer reserves the right to refuse service for safety reasons.I further agree not to hold Circle of Arms (COA) or any COA PEERS volunteer responsible or liable—financially, physically, or mentally—for any accidents or incidents that are not the result of negligence, whether occurring in a motor vehicle or outside of one.Lastly, I agree to report immediately to the COA Director any miscommunication, safety concerns, or incidents involving a COA PEER.

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