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
2 digit month, 2 digit day, 4 digit year
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:
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
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
File Upload

Cancelof
Should be Empty:

BRAG Lifeline Mobility Program Community Ride Past Trip Log