Transportation Request Form

Please be advised that HHHS Community Support Services requires a minimum of 4 business days notice for booking transportation trips. HHHS offers a medically necessary subsidy for any clients who are receiving Cancer and Dialysis treatments. Please reference this subsidy to your coordinator for more information. Filling out this form does not guarantee your trip can be completed. If you have not had confirmation from a driver or support staff within 48 hours of your request, please call 705 457 2941 ext. 2925 to confirm your booking.

Transportation Rates

Private pay rates	Van rates
0.35/KM $10/hr Wait time	0.50/KM $50/hr Wait time

I'm filling out this form for:

Myself

Someone Else

Who is this ride being billed to?

Client / Myself

Caregiver

Third-party e.g. Nursing Home

ODSP

Ontario Works

Who is taking the ride?

First Name

Last Name

Phone

Trip Details

I can ride in a regular vehicle

I can ride in a regular vehicle (require and have my own walker)

I have a wheelchair, and require a wheelchair accessible ride

I don’t have a wheelchair, and require a wheelchair accessible ride

Will anybody be accompanying you on your ride?

Yes

Trip Type

One Way Trip

Round Trip

Multi-stop Trip

Where Are We Picking You Up?

Name of Pickup Location

Street Address

Address Line 2

City

Where Do You Want to Go?

Name of Location You Are Going To

Street Address

Address Line 2

City

When Do You Need to Be There?

How long do you expect your appointment to be?

Under 1 hour

1-2 hours

Longer than 2 hours

I require assistance during pick up

I require assistance to get into my destination

My residence has stairs that I require assistance with

Special Instructions