Request a Ride - River Valley Senior Center

Have you used our transportation service before?

Yes No

Are you 60 or older?

Yes No

Do you live in our service area of Bridgman, Galien, Grand Beach, Harbert, Lakeside, New Buffalo, New Troy, Sawyer, Three Oaks or Union Pier?

Yes No

Full Name

Address

Phone Number

Do you need a wheelchair accesible van?

Yes No

Do you need assistance to/from van? (i.e. walker, transfer chair, vision impairment, etc.)

Yes No

If you do need assistance, please let us know what you need assitance with below.

Appointment Date:

Appointment Time:

How long do you estimate your appointment will take?

Name of Doctor:

Facility Name:

Facility Full Address:

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