Transportation Request Form
Native American Community Clinic can provide transportation to and from appointments, services, and NACC events. If you are interested in transportation, read and fill out and sign:
I understand that I must follow the directions of the driver at all times and that failure to follow the drivers instructions may disqualify me from the transportation program.
I understand that staff have the right to refuse to give me a ride if I am intoxicated, unable to stay calm, or causing problems of any kind. I understand that I may not be intoxicated, nor carry alcohol, drugs or weapons while I am in the van.
I understand that there is no eating, smoking or drinking in the van at any time.
I understand that I am not eligble for a ride if I have symptoms of, or have been recently dianosed with, COVID-19. Please ask a nurse if you have questions about your eligibility for rides.
Children must be in appropriate car seat, and adults must use seat belts at all times.
I understand the driver will wait no more than 5 minutes from my prescribed pickup time.
I understand that all activity in the NACC van is filmed by security cameras.
I understand that I need to request a ride at least 24 hours in advance of my appointment.
I understand that masks must be worn at all times while in the van.
I understand that if I have symptoms of COVID-19 including fever, cough, new lost of taste of taste or smell, new fatigue, no vomiting or diarrhea- that I am not eligible for a ride.
Name of Patient
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Pick Up Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Appointment Date And Time: What time is your appointment?
Signature
*
I understand that I may be contacted by Native American Community Clinic to verify support:
Submit
Should be Empty: