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PRE-REGISTER FOR RIDESHARE TRIPS

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New Rider Reservation Form

In order to participate in our Pilot Carolina RIDES+ Transportation Program you will need to fill out the following form. Destinations are limited to under about three miles and you can learn more on our FAQ. Submitting this form will add you to our pick-up database. Once your submission is approved you will be able to schedule a ride as soon as 48 hours in advance of your travel needs.

* Indicates required field

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Email *

Date of Birth *

Emergency Contact Name *

Emergency Contact Phone Number *

Notes regarding directions to home address (if any) *

Do you currently utilize Medicaid Transportation for doctors appointments? *

Yes No

Mobility Aids *

Wheel Chair Crutches Cane White Cane Service Dog Other

Where do you need rides? What days?

Health Care: *