Outing Request
Please use this form to request a medical or social outing.  You will receive a confirmation by email. If you do not receive the confirmation, please contact us at 503.898.0813 or supportsupervisor@ohcs.org
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Email *
Client Name *
Wheelchair Van needed: *
Responsible Party *
Responsible Party Phone Number *
Outing Date *
MM
/
DD
/
YYYY
Arrival time at client's home *
Time
:
Appointment time:
Time
:
End of outing time: *
Time
:
Recurring outing:
Clear selection
Pick up from: *
Address: *
Phone Number: *
Take to (name): *
Address: *
Phone Number: *
Other locations:
Drop off place at end of outing: *
Address:
Client will have money - how much? *
Client will purchase meal for care associate - budget? *
Client should wear mask? *
Care associate should wear mask? *
Client allowed to smoke? *
Client allowed alcohol? *
Permissible activities and/or purchases:
Not permissible activities and/or purchases:
Preferred associate: *
A copy of your responses will be emailed to the address you provided.
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