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 COA 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?

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?

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're now graciously asking for a minimum of $40 dollars donation for COA PEER Volunteer services of 5 hours or less. This will include personal door-through-door pick up from your home, transportation to you sedative procedure or special needs appointment, escort to front desk check in (some cases) wait in clinic or nearby during your procedure, pick up from hospital/clinic, (if you need to pick up meds, food or make a quick stop before taking you home please relay to volunteer beforehand) and take you home and ensure you're safe inside. If more than 5 hours is needed for our services than an additional $15 per hour (max additional hours is 3 hrs) donation is requested. Donations will be collected at the time of request form is filled out before submitting if pay electronically. If paying by cash please pay volunteer at pickup prior to your appointment. Donation can be given via check or cash (a receipt will be provided upon request) or ZELLE, Paypal, or VENMO. Please feel free to reach out to our COA PEERS admin clerk at 210-201-7048 or email infocoapeers1@gmail.com with any concerns.

I agree as a participant of the COA PEERS Program that it's completely voluntary, we're not associated with the Veterans Healthcare System or it's affiliates, to be understanding and kind to PEERS.They are volunteering their time. I agree to follow my PCM/Nursing/Staff instructions prior to and after my sedative procedure. If I don't follow my PCMs instructions, COA PEERS volunteer reserves the right to refuse service. 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.

Signature of Agreement

I plan to pay donation by

COA PEERS TRANSPORT/ESCORT SERVICE

USDDONATION AMOUNT YOU"RE GIVING, IF YOU NEED A DONATION RECIEPT PLEASE NOTIFY US. LEAVE AMOUNT BLANK IF PAYING WITH CASH

Payment Methods

Choose from one of the PayPal options to make your payment.

Register for COA PEER Program (participant)