Request for transportation services Request form for transportation services Transportation Request Form "Required" indicates required fields Your nameRequired First name Last name Email TelephoneRequiredIs this request for yourself?Required Yes No Name and phone number of the person needing transportationAnswer the other questions based on the person needing transportion.Geographic area where the person livesRequired Prescott-East Sector (Chute-à-Blondeau, Hawkesbury, L’Orignal, Ste-Anne, St-Eugène, Vankleek Hill) Prescott-West Sector (Alfred, Fournier, Lefaivre, Plantagenet, St-Bernardin, St-Isidore) Russell-North Sector (Bourget, Clarence-Creek, Curran, Hammond, Rockland, St-Pascal, Wendover) Russell-South Sector (Casselman, Embrun, Limoges, Marionville, Russell, St-Albert) Main reason for requesting the serviceRequired Medical appointment (doctor, hospital, dentist, etc.) Shopping (grocery, pharmacy, etc.) Other Other reason for transportationDate of the required transportationRequiredCheck what best describes your situationRequiredThis information will help us in selecting the best type of vehicule for your needs. I can walk, and get in and out of a vehicule by myself. I am in a wheelchair. I need help to get from my home to the vehicle, and from the vehicle to my appointment. I use a walker. Will someone else accompany you? Yes No Departure addressRequiredLocation and steet address of your destinationRequiredTime of your appointment (if you have one) Hours : Minutes AM PM AM/PM Expected duration of your appointment (if applicable)Comments
