First/Last Mile Basic Needs Questionnaire

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*** PLEASE READ ***

Thank you for expressing interest in utilizing the First/Last Mile Valet Service for your transportation needs. This form is for individuals seeking transportation to/from basic needs appointments (medical visit, wellness appointment, grocery store, Social Security Office, or DMV).

Please complete this questionnaire in it's entirety at least 2 business days (48 hours) prior to your appointment. If your appointment is less than 48 hours, give us a call to check our availability.

By completing this form does not guarantee your ride. A member of our team will call you to confirm your ride.

PLEASE NOTE: If you are looking for employment transportation (to/from work), please DO NOT complete this form. Please call our office for more information on our employment transportation service.

For questions, please contact (573) 415-0230 or admin@flmvalettransportation.org.

Name *

Phone Number *

Date of Birth *

YYYY

Gender *

Male

Female

Prefer not to say

What race/ethnicity best describes you? *

American Indian or Alaskan Native

White/Caucasian

Asian or Asian American

Black/African American

Hispanic or Latino/a

Native Hawaiian or Other Pacific Islander

Other:

Do you have any mobility challenges we should be aware of? *

Please note if you require an ADA accessible vehicle (e.g., wheelchair, lift, or stretcher accommodation), we require you schedule your ride no later than three (3) business days prior to your appointment.

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