Submit a Ride-Reqest for Ride-On Transportation

Ride Request Form for
Ride-On Transportation

Rider Information

Name

Email

Phone   Include Area Code & best phone number to be reached at

Are you Ambulatory or do you require Wheelchair Accessibility?

Do you qualify for Medi-Cal/CenCal? (Yes or No) If yes, please also
write Dr.'s Name. e.g. (Yes, Dr. Smith)  Medi-Cal/CenCal qualified individuals receive free transportation upon approval and a Doctor's prescription. To quality for this ride, you must have a prescription on file or ready before the date of the ride. Last minute Medi-Cal/CenCal rides are hard to schedule, so please have your prescription ready as many days before your requested ride as possible. Our Medi-Cal Secretary will work with you to get prescriptions approved and in our system..

Do you require an Attendant (Yes or No)?

Ride Information

Date of Ride We ask for 3 (three) Business days in advance.

Name of Destination e.g. Albertsons, New Hope Church, CHC San Luis Obispo, Home Residence,, Boo Boo Records etc. If this is a long distance medical ride (e.g. UCLA or Stanford Medical Centers), please call the office at (805) 541-8747 to request your ride as we have high demand and limited daily capacity for these rides.

Time You Would Like to Arrive at Your Destination

Pick Up Street Address and City

Pick Up Zip Code

Is this a 1-way, 2-way, or 3-way ride?

Requested Drop Off Street Addresss and City

Requested Drop Off Zip Code

Requested Return Time

For 3-way Rides Only

Time You Would Like to Be Picked Up from Your First Destination

Time You Would Like to Arrive at your 2nd Destination

Requested Second Drop Off Street Addresss and City

Requested Second Drop Off Zip Code

Requested Second Return Time

Special Requests