Mission Request – Local – groundangels.org

Patient Email *

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?

PATIENT INFO

Patient Name *

VET? *

Yes

No

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

No

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

No

TOTAL number of passengers in your group? *

Traveling companion NAME

LEAVE BLANK

Companion Mobile#

LEAVE BLANK

Please provide your Buddy mobile in case we cannot reach you

Relationship

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 Facility 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.

Note: If your request is not submitted/saved, please look up above for RED area and correct your entry.

Mission Request – Local

LOCAL HOUSTON ride Request

LOCAL Ride - Key Mission details

PATIENT INFO

Patient HOME info

Med Facility Location