MISSION RECORDS

MISSION RECORDS

LOCAL HOUSTON On-Line ride Request

LOCAL Ride - Key Mission details

Mission Type


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
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) *
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 Traveler Detail

Patient Name *
Patient Mobile# *
() -
Please enter primary contact # for Patient
Preferred Comms method?
How can our Volunteer best contact you?
VET? *
Mark YES if Patient is a Military Vet
Patient Email *
Patient Age *
PLEASE tell us the Patients Age
HGA WAIVER accepted *
Patient MUST agree YES to waive all liabilities. WAIVER can be viewed here https://groundangels.org/wp-content/uploads/2024/08/2024-Liability-Waiver.pdf
Permission to use Mission IMAGES
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 detail

Med CLINIC (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.