Impact Rides - Interest & Waitlist Form
Please select one:
*
I am a client or family member
I am a care professional at Impact
I am interested in becoming a client
I am interested in becoming a care professional
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Preferred Contact Method:
*
Phone
Text
Email
Which county are you located in or need services in?
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Wayne
Wilson
Pitt
Sampson
Duplin
Johnston
Greene
Lenoir
Other
What type of rides are you most interested in? (Check all that apply)
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Doctor's appointments
Dialysis
Pharmacy
Grocery Store
Senior Center
Rehab discharge
Visiting family
Church
Paying bills in person
Pick-up of prescriptions, food, or supplies
Other
How often do you expect to need a ride?
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Once a week
A few times a week
Once or twice a month
Only as needed
Not sure yet
Do you have any health conditions we should be aware of for transportation planning? (Check all that apply)
*
Dialysis
Cancer
Dementia or Alzheimer's
Mobility issues (wheelchair, walker, etc.)
Visual impairment / legally blind
Stroke recovery
Oxygen use / respiratory support
Fall risk
Amputation
Parkinson's
Diabetes
Seizure disorder
Behavioral / memory challenges
Chronic pain or fatigue
None at this time
Other
Are you interested in driving clients outside of your scheduled care hours?
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Yes
Maybe, I have questions
No
Do you have a reliable vehicle?
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Yes
No
Do you have a valid driver's license and clean driving record?
*
Yes
No
Need to check
Any questions or comments?
Join the Waitlist
Should be Empty: