Ride Request | America Needs Babies Foundation

RIDE REQUEST FORM

This form is used solely to request transportation assistance (Request a Ride) provided by America Needs Babies Foundation (ANBF) for non-emergency purposes.

Transportation provided by ANBF is not for emergencies. If you are experiencing a medical emergency or any emergency, call 911.

DESTINATIONS (IF DESTINATION NOT LISTED, please enter business name/address into NEW DESTINATION NOMINATION - see below) *

DATE *

TIME *

Hours

Minutes

AM/PM

Requested date and time are used for planning purposes only and do not guarantee ride availability. ANBF will confirm if a ride can be provided.

Drivers available Monday - Friday except on Federal and State holidays.

Please allow flexibility of at least plus or minus 30 minutes. Exact pickup times cannot be guaranteed.

PRIMARY CLIENT INFORMATION

First Name *

Last Name *

Age in Years - IF UNDER 18, a parent or guardian must complete this form *

MOBILE PHONE NUMBER (required) *A mobile phone number is required. ANBF uses calls and text messages for time-sensitive ride coordination. If we are unable to reach you, transportation services may be canceled. Text messages are limited to ride coordination only.

PICKUP ADDRESS

Street Address *

City *

Drop-off Address (if different from Pickup Address)

Street Address

City

Additional 1-3 Passengers

Please include children and infants in the Additional Passenger count. | ANBF does not provide car seats or booster seats. Parents or guardians are responsible for providing any legally required child safety restraints. | For the safety of all passengers, transportation services may be canceled if required safety restraints are not available or if applicable Iowa safety requirements cannot be met.

First Name

Last Name

Age in Years (list infants as '1')

First Name

Last Name

Age in Years (list infants as '1')

First Name

Last Name

Age in Years (list infants as '1')

EMERGENCY CONTACT

First Name *

Last Name *

Phone Number (required) *

Relationship to Client (required) | Additional information (optional) *

NEW DESTINATION NOMINATIONI hereby nominate the BELOW NAMED medical office, pregnancy resource center, or agency to become a DESTINATION. My nomination does not guarantee approval or transportation.

Street Address

City

State/Province

ZIP / Postal Code

CONSENT & RELEASE

I UNDERSTAND TRANSPORTATION ASSISTANCE:

1. Is provided by volunteers or contractors, is subject to availability, and is not a medical or emergency service.

2. Is provided subject to availability and does not create an ongoing obligation or entitlement to future rides.

3. Requested dates & times are not guaranteed, and do not constitute confirmation of transportation services.

4. Does does not include insurance coverage for clients and passengers beyond what is required by law.

5. May be canceled if required safety restraints (e.g., car seats and booster seats) are not available or if applicable Iowa safety requirements cannot be met.

I voluntarily request assistance and release ANBF from liability except in cases of gross negligence.

I have read and agree to the preceding Consent & Releasse