Transportation Request

Transportation Request

Must be 48 hours advance notice required. Purpose must be Drug and Alcohol treatment/recovery related. Non-Drug and Alcohol Treatment/Recovery Transport Requests will be based on Availability of Drivers. ALL TRANSPORTS ARE NOT GUARUNTEED and will be based on the order the request is made.
ATTENTION: Tohge office opens at 8AM, First pick-ups start around 8:30AM.

Weekend transports will be based on availability of drivers and are not guarunteed
Are you filling the form for yourself or for a peer?*

I am the passenger, requesting a ride for myself.I am a peer/staff member filling this out on behalf of a client.
Agreements:*

My transportation request is treatment or recovery related.I am making this request at least 48 hours prior to the date of service.I agree to notify Tohge immediately if I need to cancel, and understand that failure to cancel ahead of time may result in being blacklisted.I understand that if Tohge is unable to contact me to confirm, my request may be canceled.I understand that by submitting this form, I am not guaranteed service.
Peer/Staff Name (Your Name)*

First NameLast Name
Client's (Passenger) Name*

First NameLast Name
Client Phone Number*
Client Email
example@example.com
How many passengers?*
Passenger #1 Name

First NameLast Name
Passenger #2 Name

First NameLast Name
Passenger #3 Name

First NameLast Name
Passenger #4 Name

First NameLast Name
Check all that apply:*

Mental HealthSubstance Use ChallengeCo-OccuringOpioid UseAlcohol Use ChallengeVeteransOther
Check all that apply:*

New BeginningsGuam BehavioralWestCare VeteranWestCare Non VeteranLighthouse Recovery Center MalesLighthouse Recovery Center FemalesVeteran Treatment CourtAdult Drug CourtMental Health CourtGFRPDWITCAIU Release3.7 UnitCenter Of HopeOther
Trip Details
Date of trip*

MonthDayYear
Date
Pick-up time*

Pick-up

AM/PM Option
Purpose of Trip*
Trip type*

One wayRound tripMultiple stops
One way: A → B

Round trip: A → B → A

Multiple stops: A → B → C
Pick up location (A)*

Lighthouse Recovery CenterNew BeginningsGBHWCDistrict Court (federal)Superior Court (local)Paseo meetingMangilao meetingYigo meetingOther - enter in FULL STREET ADDRESS
Your second destination (B) must be different from the pick-up location (A.)
Drop off location / Second stop (B)*

Lighthouse Recovery CenterNew BeginningsGBHWCDistrict Court (federal)Supreme Court (local)Paseo meetingMangilao meetingYigo meetingOther - enter in FULL STREET ADDRESS
Additional stop (C)

Lighthouse Recovery CenterNew BeginningsGBHWCDistrict Court (federal)Supreme Court (local)Paseo meetingMangilao meetingYigo meetingOther
Pick-up Location
Drop Off Location
Type a question
Please read this form carefully and be aware that in consideration for Tohge, you will be expressly assuming the risk and legal liability and waiving and releasing all claims for injuries, damages or loss which you might sustain as a result of said services, including but not limited to, vehicle operations and boarding and exiting the vehicle.

I recognize and acknowledge that Tohge is neither a common carrier nor in the business of providing transportation services to the public. I further recognize and acknowledge that there are certain risks of physical injury to vehicle passengers, and I voluntarily agree to assume the full risk of any injuries, damages or loss, regardless of severity, that I may sustain as a result of participating in any and all activities connected with or associated with receiving transportation services, including, but not limited to, injuries, damages and loss arising out of negligent operation or supervision of the vehicle. I further agree to waive and relinquish all claims I may have (or accrue to me) against Tohge, including its respective officials, agents, volunteers and employees (hereinafter collectively referred to as “Party”).

I do hereby fully release and forever discharge the Party from any and all claims for injuries, damages or loss that I may have or which may accrue to me and arising out of, connected with, or in any way associated with said transportation services.
I further agree that this agreement shall be governed by the laws of Guam.
I have read and fully understand the above waiver and release of all claims. My on-line or facsimile signature shall substitute for and have the same legal effect as an original form signature.

I, the passenger swear to not be in possesion of any illegal substances and/or under the influence of any illegal substances. Also willing to be searched and/or provide a drug test sample at any moment if requested by Tohge Driver. I understand that if a Drug/Alcohol test is requested by the Tohge driver and I, the passenger refuse the requests for a Drug test sample, I will forefeit my Liability and Transport services.
WAIVER of LIABILITY -- COVID-19

The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is reported to be contagious. The state of medical knowledge is evolving, but the virus is believed to spread from person-to-person contact and possibley by contact with contaminated surfaces and objects or in the air. People reportedly can be infected and show no symptoms and therefore spread the disease. The exact methods of spread and contraction are unknown, and there is no known treatment, cure, or vaccine for COVID-19. Evidence has shown that COVID-19 can cause serious and potentially life threatening illness and even death.

Tohge cannot prevent you from becoming exposed to, contracting, or spreading COVID-19 while utilizing Tohge’s services or premises. It is not possible to prevent against the presence of the disease. Therefore, if you choose to utilize Tohge’s services and/or enter onto Tohge’s premises you may be exposing yourself to and/or increasing your risk of contracting or spreading COVID-19.

ASSUMPTION OF RISK -- I have read and understood the above warning concerning COVID-19. I hereby choose to accept the risk of contracting COVID-19 for myself and/or my children in order to utilize Tohge’s services and enter Tohge’s premises. These services are of such value to me [and/or to my children,] that I accept the risk of being exposed to, contracting, and/or spreading COVID-19 in order to utilize Tohge’s services and premises in person.

WAIVER OF LAWSUIT/LIABILITY.-- I hereby forever release and waive my right to bring suit against Tohge and its owners, officers, directors, managers, officials, trustees, agents, employees, or other representatives in connection with exposure, infection, and/or spread of COVID-19 related to utilizing Tohge’s services and premises. I understand that this waiver means I give up my right to bring any claims including for personal injuries, death, disease or property losses, or any other loss, including but not limited to claims of negligence and give up any claim I may have to seek damages, whether known or unknown, foreseen or unforeseen.
Signature*

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Should be Empty:

Transportation Request

ATTENTION: Tohge office opens at 8AM, First pick-ups start around 8:30AM.

Trip Details