Transportation Request Form

Transportation Request Form
This service is for participants who have opted into the add-on monthly transportation option.
Participant Name:
Unit Number:
Room Number:
Date of Request:

MonthDayYear
Date
Trip Information
Date of Transportation Needed:

MonthDayYear
Date
Pick-Up Time:

Hour Minutes

AM/PM Option
Appointment/Arrival Time:

Hour Minutes

AM/PM Option
Reason for Transportation
Other:
Additional Information

Please provide any special instructions or important details:
Transportation Policy
- Transportation requests should be submitted at least 72 hours in advance whenever possible.
- Transportation is scheduled based on driver availability.
- Participants should be ready at the scheduled pick-up time.
- Transportation is available only within the approved service area (Saginaw) unless otherwise authorized.
- Missed appointments, excessive wait times, or additional stops may result in additional fees.
- Outing can be no longer than 2 hours if driver has to wait.
- Can only schedule up to 4 outings a month.
- Emergency transportation is not provided. In an emergency, call 911.
Participant Acknowledgment
I certify that the information provided is accurate. I understand that transportation requests are subject to availability and approval by RAD Supportive Living, LLC. I also understand that transportation services are intended for approved purposes and may be limited based on scheduling and staffing.
Participant Signature:
Date:

MonthDayYear
Date
Reason for Transportation:
Destination location:
Will a Return Trip Be Needed?
Requested Return Time (if known):
Staff Approval:
Date:

MonthDayYear
Date
Driver Assigned:
Pick-Up Time Confirmed: