Ride Request | Epilepsy DE

First name

Last name

Phone Number

This phone number will be used to receive your ride information.

Ride Type

One-way Trip

Round Trip

Pickup Time

Time

HoursMinutes

Pickup Date

1st Leg: Pickup Address

1st Leg Destination

2nd Leg: Pick-up Time

Time

HoursMinutes

Flexible Pickup

*When choosing a flexible pickup, you will receive a text to reply to when you are ready for pickup. Please do not delete this text! Doing so will prevent you from calling for your ride.

Purpose of the ride. (used for reporting purposes only)

Medical Appointment

Social/Personal

EFDE Event

Other

Trusted Contact Person

This person will receive ride updates and tracking information.

Trusted Contact Phone Number

This should be a mobile number to receive ride tracking information.

Additional Notes/Comments:

Ride Request Form

If you have not yet been approved for EFDE's Transportation Program please use this link to enroll.

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