Ride Request Form

DDS Riders Please Use the Form Located Here: https://goodnewsgarage.org/dds-ride-request-form/

Ready To Go Ride Request Form

A copy of this ride request will be sent to the Case Manager’s email as it is entered below.

Step 1 of 8

A copy of this ride request will be sent to the Case Manager’s email as it is entered below.
Case Manager Information
Case Manager's Name*
First Last
Case Manager's Phone*
Case Manager's Email*
Affiliation*
What agency or organization are you with?

Rider Information
Rider's Name*
First Last
Rider's Date of Birth*
MM slash DD slash YYYY
Rider's Gender*
- Male
- Female
- Other
Last 4 Digits of Rider's Social Security Number*
Rider's Cell Phone Number*
Rider's Home/Other Phone Number
Rider's Email Address*
Would you like to sign your rider up for automated trip reminders?
Pick-Up Address*
Street Address Address Line 2 City State
Is the Rider's Mailing Address the same as the Pick-Up address?*
- Yes
- No
Rider's Mailing Address*
Street Address Address Line 2 City State ZIP Code
Number of Child Riders*
Date of Birth of Child 1*
MM slash DD slash YYYY
Date of Birth of Child 2*
MM slash DD slash YYYY
Date of Birth of Child 3*
MM slash DD slash YYYY
Date of Birth of Child 4*
MM slash DD slash YYYY
Does this ride require a childcare stop?*
Childcare Information
Name of Childcare*
Childcare Address*
Street Address Address Line 2 City State
Destination Information
Start Date*
MM slash DD slash YYYY
End Date*
MM slash DD slash YYYY
Days of the Week*
Hold the CNTRL key to select multiple days
Appointment Time*

: Hours

Minutes

AM/PM
Return Time*

: Hours

Minutes

AM/PM
Destination Name*
Destination Address*
Street Address Address Line 2 City State
Special Instructions
Please be as specific as possible.
If Ready To Go is unable to fulfill this request immediately, would you like the request added to the waitlist?*
- Yes
- No
Type of Ride*
Purpose of Ride*
Purpose of Ride*
Countable Ride?*
Duration*
District*
I have reviewed a copy of the Rider Protocols with my client*
yes
View the Rider Protocols

Rider Information
Rider's Name*
First Last
Rider's Date of Birth*
MM slash DD slash YYYY
Rider's Gender*
- Male
- Female
- Other
SSMIS Number*
Pick-Up Address*
Street Address Address Line 2 City State
Is the Rider's Mailing Address the same as the Pick-Up address?*
- Yes
- No
Rider's Mailing Address*
Street Address Address Line 2 City State ZIP Code
Foster/Caretaker Information
Foster/Caretaker's Name*
First Last
Foster/Caretaker's Cell Phone*
Foster/Caretaker's Other Phone
Foster/Caretaker's Email Address*
Would you like to sign the rider's foster/caretaker up for automated trip reminders?
Destination Information
Start Date*
MM slash DD slash YYYY
End Date*
MM slash DD slash YYYY
Days of the Week*
Hold the CNTRL key to select multiple days
Appointment Time*

: Hours

Minutes

AM/PM
Return Time*

: Hours

Minutes

AM/PM
Destination Name*
Destination Address*
Street Address Address Line 2 City State
Special Instructions
Please be as specific as possible.
If Ready To Go is unable to fulfill this request immediately, would you like the request added to the waitlist?*
- Yes
- No
Duration*
District*
I have reviewed a copy of the Rider Protocols with my client*
yes
View the Rider Protocols

Rider Information
Rider's Name*
First Last
Rider's Date of Birth*
MM slash DD slash YYYY
Rider's Gender*
- Male
- Female
- Other
Last 4 Digits of Rider's Social Security Number*
Rider's Cell Phone*
Rider's Home/Other Phone
Rider's Email Address*
Would you like to sign your rider up for automated trip reminders?
Pick-Up Address*
Street Address Address Line 2 City State
Destination Information
Start Date*
MM slash DD slash YYYY
End Date*
MM slash DD slash YYYY
Days of the Week*
Hold the CNTRL key to select multiple days
Appointment Time*

: Hours

Minutes

AM/PM
Return Time*

: Hours

Minutes

AM/PM
Destination Name*
Destination Address*
Street Address Address Line 2 City State
Special Instructions
Please be as specific as possible – special drop off/pick up procedures, etc.
If Ready To Go is unable to fulfill this request immediately, would you like the request added to the waitlist?*
- Yes
- No
Purpose of Ride*
Duration*
I have reviewed a copy of the Rider Protocols with my client*
yes
View the Rider Protocols

Rider Information
Rider's Name*
First Last
Rider's Date of Birth*
MM slash DD slash YYYY
Rider's Gender*
- Male
- Female
- Other
Last 4 Digits of Rider's Social Security Number*
Rider's Cell Phone*
Rider's Home/Other Phone
Rider's Email Address*
Would you like to sign your rider up for automated trip reminders?
Pick-Up Address*
Street Address Address Line 2 City State
Destination Information
Start Date*
MM slash DD slash YYYY
End Date*
MM slash DD slash YYYY
Days of the Week*
Hold the CNTRL key to select multiple days
Appointment Time*

: Hours

Minutes

AM/PM
Return Time*

: Hours

Minutes

AM/PM
Destination Name*
Destination Address*
Street Address Address Line 2 City State
Special Instructions
Please be as specific as possible.
If Ready To Go is unable to fulfill this request immediately, would you like the request added to the waitlist?*
- Yes
- No
Purpose of Ride*
Duration*
I have reviewed a copy of the Rider Protocols with my client*
yes
View the Rider Protocols

Rider Information
Rider's Name*
First Last
Rider's Date of Birth*
MM slash DD slash YYYY
Rider's Gender*
- Male
- Female
- Other
Pick-Up Address*
Street Address Address Line 2 City State
Guardian's Information
Guardian's Name*
First Last
Guardian's Cell Phone*
Guardian's Home/Other Phone*
Guardian's Email Address*
Would you like to sign the guardian up for automated trip reminders?
Destination Information
Start Date*
MM slash DD slash YYYY
End Date*
MM slash DD slash YYYY
Days of the Week*
Hold the CNTRL key to select multiple days
Appointment Time*

: Hours

Minutes

AM/PM
Return Time*

: Hours

Minutes

AM/PM
Destination Name*
Destination Address*
Street Address Address Line 2 City State
Special Instructions
Please be as specific as possible.
If Ready To Go is unable to fulfill this request immediately, would you like the request added to the waitlist?*
- Yes
- No
Duration*
I have reviewed a copy of the Rider Protocols with my client*
yes
View the Rider Protocols

Rider Information
Rider's Name*
First Last
Rider's Date of Birth*
MM slash DD slash YYYY
Rider's Gender*
- Male
- Female
- Other
Pick-Up Address*
Street Address Address Line 2 City State
Guardian's Information
Guardian's Name*
First Last
Guardian's Cell Phone*
Guardian's Home/Other Phone*
Guardian's Email Address*
Would you like to sign the guardian up for automated trip reminders?
Destination Information
Start Date*
MM slash DD slash YYYY
End Date*
MM slash DD slash YYYY
Days of the Week*
Hold the CNTRL key to select multiple days
Appointment Time*

: Hours

Minutes

AM/PM
Return Time*

: Hours

Minutes

AM/PM
Destination Name*
Destination Address*
Street Address Address Line 2 City State
Special Instructions
Please be as specific as possible.
If Ready To Go is unable to fulfill this request immediately, would you like the request added to the waitlist?*
- Yes
- No
Duration*
I have reviewed a copy of the Rider Protocols with my client*
yes
View the Rider Protocols
Untitled

Ride Request Form

DDS Riders Please Use the Form Located Here: https://goodnewsgarage.org/dds-ride-request-form/

Ready To Go Ride Request Form

Step 1 of 8

Case Manager Information

Rider Information

Childcare Information

Destination Information

Guardian Information

Childcare Information

Emergency Contact Information

Rider Agreements

Rider Information

Foster/Caretaker Information

Destination Information

Rider Information

Destination Information

Rider Information

Destination Information

Rider Information

Guardian's Information

Destination Information

Rider Information

Guardian's Information

Destination Information