Alpha Mobility Mission, Inc.

Expanding Horizons…Maximizing Potential

Request for Transportation

Applicant’s Name: __________________________________ Date of Request: ______________

Address: ______________________________________________________________________

City: ___________________________ State: ___________________ Zip: __________________

County: ______________________ DOB: _____/____/____

How did you hear about our service? ________________________________________________

Phone Numbers: Home ____________________ Cell/Mobile ____________________________

E-Mail: ________________________ How do you want us to contact you? _________________ 

Alpha Mobility Mission, Inc. reviews each application individually.  We do not make our decision with any regard to ethnicity, gender, age, religious affiliation, or type (if any) of disability.  All information on this form is treated with the same confidentiality as medical records.  We reserve the right to prioritize the use of available funds and/or equipment.

 
Will you be traveling with children? _____ If so, please provide their names and ages: ____________

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Do you have custody? ______ If so, can you provide a copy of a Divorce Degree? _______________

(Permission of the Custodial Parent is required for minors.) 

Additional Travel Requirements (list if any, i.e., oxygen, assistance animal, or attendant): _________

_________________________________________________________________________________

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Degree of Mobility (Please be specific so we can assist you best): ____________________________

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Type of Travel required: _____________________________________________________________

Starting Point: _______________________________ Ending Point: __________________________

Routing Preferences (if any): _________________________________________________________

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Departure Date: ___________________________ Arrival Date: _____________________________

Destination Confirmation Contact (Name and Phone Number): ______________________________

Are you Medically Stable enough to Travel? ________ List Medical/Mobility Considerations: _____

_________________________________________________________________________________

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Doctor’s Office Point of Contact: Name ____________________ Phone: ______________________

Were you referred by a medical professional, counselor, clergy, or court officer? ________________

If so, whom, and what office/agency? ___________________________________________________

Will any of the expense of this trip be covered by insurance? ________________________________

If so, how much (approximately): ______________________________________________________ 
 

What percentage of the expenses for the trip will Alpha Mobility Mission, Inc. need to cover?    

            (Please Circle One)  10%      25%    50%     75%     100% 

Make a brief statement explaining why or how this trip or move is necessary, or how it would benefit your circumstances.  Be honest:  all information on this form is strictly confidential.

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Important for applicant/agent (1) Acceptance for purposes of review and eligibility determination of this application in no way obligates Alpha Mobility Mission, Inc. to provide services or funds.  (2) Alpha Mobility Mission, Inc. reserves the right to purchase transport services or other products from third party providers.  (3) Applicant/Agent agrees that the act of accepting services or funds from Alpha Mobility Mission, Inc. excuses this organization and grants total immunity from liability or loss arising from any accidents, injury, or other event which occurs while using commercial third party service providers.  Further, Applicant/Agent understands that unless specific arrangements are made and documented in advance, Alpha Mobility Mission, Inc. accepts no liability or responsibility for any situation, circumstance, or event occurring after contracted services have been rendered.

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Office Use Only:  Do Not Write Below This Line! 
 
 
 

Form Completed By: _____________________________________ Date: _____________________

Reviewed By: __________________________________________ Date: ______________________

Estimated Expenses: ________________________________________________________________

_________________________________________________________________________________

Decision: _________________________________________________________________________

Applicant Notification By: ________________________________Date: ______________________

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