Willing To Care Shuttle Transport Service Registration

Willing To Care Shuttle Transport Service Registration

Please fill out the form below to register your interest in our shuttle transport service.
Passenger's Full Name*

First NameLast Name
NDIS Number*
Guardian's Name*

First NameLast Name
Contact Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Are you self managed?

YesNo
Plan Manager Company Name
Plan Manager Contact Name
Plan Manager Phone Number
Please enter a valid phone number.
Plan Manager Email Address
example@example.com
Please Upload any Medical Management Plan that will assist us to make your young person experience safe.

Cancelof
Pick Up Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Select the days you are interested in for shuttle service

MondayTuesdayWednesdayThursdayFriday
Select preferred time slots (AM or PM)

AMPM

MEDICAL MANAGEMENT PLAN DISCLOSURE DISCLAIMER
Transportation Services for Special Needs Clients

IMPORTANT NOTICE: FAILURE TO DISCLOSE COMPLETE MEDICAL MANAGEMENT PLAN MAY AFFECT TRANSPORTATION SERVICES BETWEEN HOME AND WILLING TO CARE

Service Context

Drivision Mobility Solutions provides specialized transportation services for special needs clients traveling between their homes and Willing to Care facilities. Safe transportation requires complete knowledge of each client's medical and care management plan.

Required Medical Disclosure Information

All clients and their caregivers/guardians must provide complete and accurate information regarding:

Medical Conditions & Treatments:
- Current medical diagnoses and conditions
- Medications and administration schedules
- Medical devices (oxygen, feeding tubes, catheters, etc.)
- Mobility aids and assistive equipment
- Seizure protocols and emergency procedures
Behavioral & Communication Needs:
- Behavioral management strategies
- Communication methods and preferences
- Sensory sensitivities or triggers
- Comfort items or calming techniques
- Emergency behavioral intervention plans
Physical Care Requirements:
- Positioning and transfer needs
- Dietary restrictions during transport
- Bathroom/personal care requirements
- Temperature regulation needs
- Emergency medical contacts and procedures
Potential Consequences of Non-Disclosure

Immediate Safety Risks:
- Inability to respond appropriately to medical emergencies
- Unsafe transport methods or positioning
- Medication conflicts during extended transport
- Inadequate preparation for behavioral episodes
- Compromised client comfort and well-being
Service Limitations:
- Suspension or termination of transportation services
- Requirement for additional medical clearances
- Mandatory escort or nursing support during transport
- Restricted transport times or routes
- Enhanced liability insurance requirements
Administrative Impact:
- Delayed service initiation or resumption
- Required reassessment by medical professionals
- Additional staff training requirements
- Increased documentation and monitoring protocols
- Potential transfer to alternative transport providers
Client/Guardian Responsibilities
By utilizing Drivision Mobility Solutions services, you acknowledge:
1. Complete Disclosure: You will provide comprehensive information about the client's medical management plan
2. Ongoing Updates: You will immediately notify us of any changes to medical conditions, medications, or care requirements
3. Emergency Information: You will ensure current emergency contacts and medical directives are on file
4. Collaboration: You will work with our team to develop safe transport protocols
5. Compliance: You understand that incomplete disclosure may result in service modifications or termination
Our Commitment to Safe Transport

Drivision Mobility Solutions is committed to:
- Providing safe, dignified transportation for all clients
- Training staff on special needs care and emergency procedures
- Maintaining appropriate vehicles and safety equipment
- Coordinating with Willing to Care for seamless service delivery
- Protecting client privacy while ensuring safety
Legal and Safety Considerations

This disclosure policy ensures:
- Compliance with transportation and healthcare regulations
- Protection of client safety during transport
- Appropriate risk management and insurance coverage
- Clear communication between all care providers
- Documentation of safety protocols and procedures
ACKNOWLEDGMENT

By ticking the box above, the client/guardian acknowledges:
- Receipt and understanding of this disclosure policy
- Agreement to provide complete medical management information
- Understanding that service availability depends on full disclosure
- Acceptance of responsibility for consequences of non-disclosure
Should be Empty: