MISSION RECORDS
MISSION RECORDS
» LOCAL HOUSTON On-Line ride Request
LOCAL HOUSTON On-Line ride Request
LOCAL Ride - Key Mission details
Mission Type
IN Bound
OUT Bound
IN Bound is TO the Med Center. OUT Bound is going OUT from Med Center
Mission Date
*
We MUST know when you are travelling
Date & Time MUST be 2 days ahead
No
Yes
DO NOT request a ride unless we have at least 48 hours = 2 days for our volunteers to be able to view.
PU Place (LOCAL only)
*
Residence
Med Clinic
Other
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 ?
*
AM
PM
PLEASE confirm PU Time - AM or PM ?
Patient Traveler Detail
Patient Name
*
Patient Mobile#
*
(
)
-
Please enter primary contact # for Patient
Preferred Comms method?
CALL
TEXT
How can our Volunteer best contact you?
VET?
*
No
Yes
Mark YES if Patient is a Military Vet
Patient Email
*
Patient Age
*
PLEASE tell us the Patients Age
HGA WAIVER accepted
*
No
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
No
Yes
Traveling companion NAME
Companion Mobile#
(
)
-
Please provide your Buddy mobile in case we cannot reach you
Relationship
(None)
Parent
Child
Spouse
Caregiver
Other
Tot# Pass
*
1
2
3
4
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 detail
Med CLINIC (LOCAL only)
*
DROP DOWN or special Street Address - FILL IN BELOW
MDA Main lobby - 1515 Holcombe
MDA Mays Clinic, Entrance #7
MDA Proton, 1840 Old Spanish Trail
Baylor-St_Lukes Liver/Kidney, 6620 Main
Baylor-St.Lukes Transplant, 6720 Bertner
MEM-Hermann Transplant, Jones Pavilion, 6411 Fannin
MEM-Hermann Advanced Cardio, 6400 Fannin
Methodist OPC - 6565 Fannin
Methodist Cancer Clinic, 1130 Earle
UT Professional, 6655 Travis St.
DeBakey VA Center, 2002 Holcombe Blvd
Smith Clinic, 2525 Holly Hall.
TX Oncology, 501 W. Medical Cent Blvd, Webster 77598
MD Anderson WEST - 13900 Katy Fwy 77079
MDA The Woodlands, 100 Fellowship Dr. 77384
Mem-Hermann, 920 Medical Plaza Dr, 77380
Provide the street address - FILL IN BELOW
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.