Transportation Request Form

Transportation Request Form

Please provide details for your ride request. Please note we cannot guarantee rides as we are a volunteer driven service. You will be contacted by our office either way.
Are you currently a client/have you completed an intake?
You may not request a ride until you have completed an intake AND our staff have contacted you to let you know you are eligible to request service. Please visit www.routescc.org/intake to start the process.
Will you be bringing any of the following mobility devices?
Full Name

First NameLast Name
Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Pick Up Address (Typically Home)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Destination Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have any additional stops? (i.e. Bank, Pharmacy, etc.)
Additional Stop 1 ($2 Fee + Mileage)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Additional Stop 2 ($2 Fee + Mileage)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Trip Type:
Date & Time of your Appointment/Visit (Note: This is arrival time, not pickup time). For ride requests within 2 business days, you must call our office immediately.

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour MinutesAM/PM Option
Duration of Appointment
Any additional passengers?
Full Name (intake must be completed)
What is this ride for? (i.e.: Medical, Bloodwork, Social Visit, Shopping, etc.)
Honesty is the best policy. Please note that volunteers often report back if something is labelled Medical but is something else.
Is your appointment Flexible (bloodwork, walk-in, shopping), or Fixed (booked appointment at a set time)?
Flexible appointment arrivals may be adjusted based on driver availability. We will honour your preferred time whenever possible.
How Do You Pay For Your Rides?
Who is the funder?
Should be Empty: