B.E.A.T.S. Seizure-Safe Rides Sign-Up Form
💜 Thank you for your interest in B.E.A.T.S. Seizure-Safe Rides. Please complete this form to enroll. This information helps us coordinate safe, reliable transportation through Uber Health.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
Date
Email Address
example@example.com
Phone Number
*
Please enter a valid phone number.
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Appointment Scheduling
Preferred pick-up date and time for your ride.
Emergency Contact
Contact Name
*
First Name
Last Name
Relationship (parent, spouse, caregiver, etc.)
*
Relationship
Full Name
Phone Number
*
Please enter a valid phone number.
Medical Notes (Optional)
Do you have any special considerations we should be aware of?
Preferred hospital or doctor (optional)
Consent & Release of Information
By signing below, I understand that B.E.A.T.S. coordinates rides using Uber Health but does not provide the transportation directly. I release B.E.A.T.S. from liability for delays, accidents, or emergencies that may occur during transportation.
Signature
Full Name
First Name
Last Name
Briefly describe your interest in epilepsy awareness and healthcare rides.
Submit
Submit
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