DAR Online Scheduling Form

Rider Name Rider Name First Last
Scheduler Name (if not rider) Scheduler Name (if not rider) First Last
How would you like to be notified of your scheduled times; by phone and/or email?

How would you like to be notified of your scheduled times; by phone and/or email? Phone Email
Phone Phone - ### - ### ####
Email
Date(s) of Ride Date(s) of Ride / MM / DD YYYY
Pickup Address Pickup Address
Street Address
Pickup Location Name
Dropoff Address Dropoff Address
Street Address
Dropoff Location Name
Is this an appointment?

Is this an appointment? Yes No
If yes, please provide your appointment time If yes, please provide your appointment time : HH MM AM/PM
Requested Pickup Time From Pickup Address Requested Pickup Time From Pickup Address : HH MM AM/PM
Requested Arrival Time at Dropoff Address Requested Arrival Time at Dropoff Address : HH MM AM/PM
Requested Return Ride Pickup Time Requested Return Ride Pickup Time : HH MM AM/PM
Going back to pickup location? (If not, please submit a different request for a scheduled ride.)

Going back to pickup location? (If not, please submit a different request for a scheduled ride.) Yes No
PCA?

PCA? Yes No
Guest?

Guest? Yes No
Service Animal?

Service Animal? Yes No