My Ride Connection Scheduler

Ride Scheduling Form

Powered By Volunteer Drivers
Passenger

Please list the contact information of the registered passenger.
Prefix Name

Dr.Mr.Mrs.Ms.
Today's Date

MonthDayYear
Date
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Additional Passenger Waiver

Every additional passenger must have an authorized signed consent to be eligible for a ride.
Will anyone be traveling with you?*

NoYes
If yes, what is their name?

First NameLast Name

Ride Request – For Approved Applicants Only

Please complete the information below to help us arrange your transportation. Note: All ride requests must be submitted at least 72 hours before your scheduled appointment to allow time to assign a driver.
Pick up Date:

MonthDayYear
Date
Pick Up Time:

Hour Minutes

AM/PM Option
Pick Up Location Address:

Street Address

Apartment Number

CityState / Province

Postal / Zip Code
Drop Off Location
Name of drop off facility or physician: For example Dr. James York or Christian Hospital Northeast.
Drop Off Location Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Appointment Date and Time
Duration of Stay

Less than 1 hour1-2 hours2-3 hoursMore than 3 hours
Special Instructions or Needs (if any)
Reminder: Members need to be able to independently get in and out of the vehicle. Please ensure you can do so, or make arrangements to have assistance available if needed.

Please read and acknowledge the following conditions regarding the Ride Scheduling process for Circle of Care St. Louis' My Ride Connection:

Ride Confirmation:
I understand that completing the Ride Scheduling form does not guarantee a ride. My ride is only confirmed once I have received direct communication from a Circle of Care St. Louis representative.

Volunteer Availability:
I am aware that rides depend on the availability of volunteer drivers. I agree to have a backup transportation plan if a volunteer is unavailable at the requested date and time.

Payment Requirement:
I acknowledge that rides will not be scheduled until Circle of Care St. Louis successfully receives and processes my payment.

This form serves as a digital acknowledgment and agreement to the ride scheduling terms of Circle of Care St. Louis, ensuring transparency and mutual understanding in the electronic handling of ride arrangements.
By affirming my digital signature below, I confirm my understanding and acceptance of all inherent risks involved with utilizing the transportation services of Circle of Care, St. Louis's My Ride Connection program. I hereby relinquish any claims that may arise, whether directly or indirectly, from incidents that occur during the use of such transport services, due to negligence, breach of contract, or other causes. This waiver includes all claims related to personal injury, property damage, or other losses.

I also agree to discharge and hold harmless Circle of Care, St. Louis, its My Ride Connection program, and their respective successors, officers, directors, agents, volunteers, employees and related parties from any liabilities, losses, costs, or expenses linked to these waived claims.

In the event of a medical emergency during a ride, I comprehend that the driver is instructed to contact 911 and follow the guidance provided. Information on emergency procedures and protocols can be requested from the Circle of Care, St. Louis office.

I acknowledge that should my prepaid account with My Ride Connection remain inactive for six months despite attempts to contact me, all remaining funds will be forfeited and will subsequently become the exclusive property of My Ride Connection.
Signature

Clear
My Ride Connection Fee(s)

prevnext( X )
USDDescription

Payment Methods

Debit or Credit Card

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

Should be Empty:

Ride Scheduling Form

Passenger

Additional Passenger Waiver

Ride Request – For Approved Applicants Only

Drop Off Location