Transportation Request Form

Transportation Request Form
General Information
Hours of Availability for Transportation Assistance:
- Monday: 9 am to 6 pm
- Tuesday: 9 am to 6 pm
- Wednesday: 9 am to 6 pm
- Thursday: 9 am to 6 pm
- Friday: 9 am to 6
- Saturday: NO Transportation Assistance
- Sunday: NO Transportation Assistance
No transportation on most major national holidays:
- New Year's Day
- Birthday of Martin Luther King, Jr.
- Easter
- Mother's Day
- Memorial Day
- Father's Day
- Juneteenth National Independence Day (or day observed)
- Independence Day (or day observed)
- Labor Day
- Indiginous Rememberance Day (10/12)
- Veterans Day
- Giving Thanks Day (the fourth Thursday of November)
- Christmas Eve
- Christmas Day
Policies
- We reserve the right to suspend transportation requests for holiday breaks based on Jefferson County Public Schools calendar, as well as staff vacations.
- Transportation assistance must be submitted at least 24 hours prior to your obligation. We will not gaurantee transportation for requests made less than 24 hours in advance.
- We will approve transportation requests with less than a 24 hour notice ONLY if it is for a last minute schedule change by a doctor's office or tranfusion center.
- We understand that circumstances can change and/or providers can make last minute changes, but you will be limited to one transportation detail change.
- Transportation will only be arranged for individuals who are at least 18 years old.
- These behaviors towards the Nonprofit, including any of it's associates or volunteers, or the 3rd Party Transportation company will result in termination of transportation assistance:
  - Theft
  - Harassment of any type, including but not limited to
    
    excessive phone calls, messages, or texts regarding your transportation
    
    verbal aggression, such as yelling, cursing, shaming, demeaning the SCAK representative or 3rd party transportation company.
  - Physical violence or threats of physical violence against others at any time (even “playful” threats will not be tolerated), including but not limited to
    
    any digital communications (social media posts, email, or text),
    
    virtual/in-person meetings, and
    
    events.
Acknowledgement of Transportation Assistance Policies*

I have read the above policies and understand that violation of these policies could result in the termination of transportation assistanceI understand that the Sickle Cell Association of Kentuckiana, Inc reserves the right to terminate any communication or request for transportation assistance due to violation of the above policies.
Digital Signature*

First NameLast Name
Today's Date*

MonthDayYear
Transportation Request
Name of Individual Being Transported*

First NameLast Name
Place of Residency*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Date of Obligation*

MonthDayYear
Time of Requested Pickup*

Hour Minutes

AM/PM Option
What type of structure is the pickup address?*

single family detached homemultifamily unitapartment complextown homes/condominiumsOther
Pickup Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Destination*
Destination Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Info
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Please choose your response.*

I affirm that I am of legal age and able to sign on my own behalf and am freely agreeing to SCAK's 3rd Party Transportation Release & Waiver of Liability. I have read the above linked document and fully understand that by checking this box, I am giving up legal rights and remedies that may be available to me and to other persons.I affirm that I am the parent or legal guardian of the participant and am agreeing to SCAK's 3rd Party Transportation Release & Waiver of Liability on their behalf. I certify that I have the authority to sign on behalf of the participant and to make decisions for the participant. I also waive and release Sickle Cell Association of Kentuckiana, Inc. Parties from any and all liability, claims, costs, and damages of any kind which I may have resulting or arising directly or indirectly from the participant’s participation in aforementioned activities. I have read this release & waiver of liability and fully understand that by checking this box, I am giving up legal rights and remedies that may be available to the participant, to me, and to other persons.**I DO NOT consent to sign SCAK's 3rd Party Transportation Waiver of Liability & Release. I understand that my transportation request will be immediately terminated. I understand that I will NOT receive transportation assistance and will need to find an alternate method to my obligation.
Please choose your response.

I affirm that I am of legal age and able to sign on my own behalf and am freely agreeing to SCAK's 3rd Party Transportation Release & Waiver of Liability. I have read the above linked document and fully understand that by checking this box, I am giving up legal rights and remedies that may be available to me and to other persons.I affirm that I am the parent or legal guardian of the participant and am agreeing to SCAK's 3rd Party Transportation Release & Waiver of Liability on their behalf. I certify that I have the authority to sign on behalf of the participant and to make decisions for the participant. I also waive and release Sickle Cell Association of Kentuckiana, Inc. Parties from any and all liability, claims, costs, and damages of any kind which I may have resulting or arising directly or indirectly from the participant’s participation in aforementioned activities. I have read this release & waiver of liability and fully understand that by checking this box, I am giving up legal rights and remedies that may be available to the participant, to me, and to other persons.**I DO NOT consent to sign SCAK's 3rd Party Transportation Waiver of Liability & Release. I understand that my transportation request will be immediately terminated. I understand that I will NOT receive transportation assistance and will need to find an alternate method to my obligation.
** I understand that this option is ONLY for ADULTS (18+ years) with disabilities.
Electronic Signature

First NameLast Name
Relationship to Client
self/ guardian/ parent
Today's Date

MonthDayYear
Please allow 3-6 hours for processing. A representative from SCAK will contact you reguarding your request.
Should be Empty:

Transportation Request Form

General Information

Policies

Transportation Request

Emergency Contact Info