Mission Request – Local – groundangels.org

LOCAL Ride - Key Mission details

We MUST know when you are travelling

In Bound

Out Bound

IN Bound is TO the Med Center. OUT Bound is going OUT from Med Center

PU Place *

Med Clinic

Other

Residence

Where are we picking you up??

Pick Up Time *

Use clock icon to set - time. When do you want to be picked up?

Just checking - AM or PM ? *

PLEASE confirm PU Time - AM or PM ?

PATIENT INFO

Patient Name *

VET? *

Yes

Mark YES if Patient is a Military Vet

Patient Mobile# *

Please enter primary contact # for Patient

Preferred Comms method?

Call

Text

How can our Volunteer best contact you?

Patient Age *

PLEASE tell us the Patients Age

HGA WAIVER accepted *

Yes

Patient MUST agree YES to waive all liabilities. WAIVER can be viewed here https://groundangels.org/about-us/forms-downloads/liability-waiver/

Permission to use Mission IMAGES

Yes

Patient Email *

Traveling companion NAME

Companion Mobile#

Please provide your Buddy mobile in case we cannot reach you

Relationship

Tot# Pass *

TOTAL number of passengers in your group?

Patient HOME info

City *

Patient HOME City

HOME Zip *

Patient HOME Address

For HOUSTON residents only - NOT air travellers

Home near what Cross Streets?

What are the nearest major cross streets?

Pick Up Notes

Med Center Location

Med Center Clinic/Hotels (LOCAL only) *

PLEASE first CHECK if your location is in the drop down list. If NOT - please enter the Street address below.

Special Address

Zip

Med Center Notes

Add any helpful notes here if needed.

Mission Request – Local

LOCAL HOUSTON On-Line ride Request

LOCAL Ride - Key Mission details

PATIENT INFO

Patient HOME info

Med Center Location