Individual Non-Medical Transportation

Purposeful Community Connections.

We are welcoming smiles, helping hands, and encouraging companions for your journey.

If your trip is in less than one week please call (260) 420-3280 or (800) 743-3333 hearing impaired.

NEW clients must REGISTER before a trip can be requested.

Non-Medical Trip Request:

Name of Client*
First Last
Phone*
Best number to contact about the trip request
Email*
Name of Contact (if different from client)
First Last
Date of Trip*
MM slash DD slash YYYY
Pick Up Time*

: Hours

Minutes

AM/PM
Return Time*

: Hours

Minutes

AM/PM
Pick Up Address*
Street Address Address Line 2 City State ZIP Code
Destination Address*
Street Address Address Line 2 City State ZIP Code
Total number of riders*
Number of riders using a wheelchair*
Notes/Comments/Questions
Billing Information
Billing Contact
First Last
Billing Address same as Client Address?*
- Yes
- No
Billing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Consent*
I agree to the privacy policy.
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