Community Ride Past Trip Log

BRAG Lifeline Mobility Program Community Ride Past Trip Log
Driver Name:*
First and Last Name
Rider Name:*
First and Last Name
Trip Date:*

MonthDayYear
Trip Time:*

Hour Minutes

AM/PM Option
Origin Address:*
Street, City, State, Zip Code
Destination Address:*
Street, City, State, Zip Code
Trip Purpose*
Medical, Mental Health, Grocery Store, Pharmacy, Social Service, Education, Employment
Round trip:*

YesNo
Total Mileage:*
Explain below the reason you were unable to log the trip on Community Ride. Please attach a supporting screenshot of the issue you ran into.*
*This form is only to be used if you received an error message when trying to log a trip on Community Ride.

*This form will not be valid without a screenshot of the ongoing issue.
Driver Signature*

Clear
Date*

MonthDayYear
Date
File Upload*

Cancelof
Should be Empty:

BRAG Lifeline Mobility Program Community Ride Past Trip Log