Impact Rides - Interest & Waitlist Form

Impact Rides - Interest & Waitlist Form
Please select one:*

I am a client or family memberI am a care professional at ImpactI am interested in becoming a clientI am interested in becoming a care professional
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Preferred Contact Method:*

PhoneTextEmail
Which county are you located in or need services in?*

WayneWilsonPittSampsonDuplinJohnstonGreeneLenoirOther
What type of rides are you most interested in? (Check all that apply)*

Doctor's appointmentsDialysisPharmacyGrocery StoreSenior CenterRehab dischargeVisiting familyChurchPaying bills in personPick-up of prescriptions, food, or suppliesOther
How often do you expect to need a ride?*

Once a weekA few times a weekOnce or twice a monthOnly as neededNot sure yet
Do you have any health conditions we should be aware of for transportation planning? (Check all that apply)*

DialysisCancerDementia or Alzheimer'sMobility issues (wheelchair, walker, etc.)Visual impairment / legally blindStroke recoveryOxygen use / respiratory supportFall riskAmputationParkinson'sDiabetesSeizure disorderBehavioral / memory challengesChronic pain or fatigueNone at this timeOther
Are you interested in driving clients outside of your scheduled care hours?*

YesMaybe, I have questionsNo
Do you have a reliable vehicle?*

YesNo
Do you have a valid driver's license and clean driving record?*

YesNoNeed to check
Any questions or comments?
Should be Empty: