Drive4U Registration Form

Drive4U Registration

Once you have submitted your registration you will be able to request transportation by calling Agassiz-Harrison Community Services Society at 604-796-2585
Today's Date*

MonthDayYear
Date
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*

Area CodePhone Number
Phone Number

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address if different than above

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Any medical concerns that the drivers need to be aware of?
Do you require accompaniment?*
Do you use a mobility aid?

WheelchairWalkerCane/CrutchesOther
If using a wheelchair or walker you must be able to self transfer in and out of the vehicle. Are you able to do that?

YesNo
Fees: Clients are charged a per kilometre fee plus any parking fees.

The kms are calculated from the drivers home.

Please contact the Drive4U program coordinator for more information about the fees and any subsidies that may be available.
Eligibility Requirements for Service

. Must live within the boundaries of the District of Kent and Harrison Hot Springs.

. Must be able to provide appointment information (address, date, and time).

. Must be able to transfer in and out of vehicle with minimal help.

. Must be capable of giving the driver clear directions to the destination.

. Must be ready and available for pick up at an accessible location and at

the agreed upon time.

. Must be respectful of the driver’s time and reduce the drivers wait to a minimum.

. Must abide by instructions from the driver regarding safety and legal requirements. e.g. masks, hand sanitizer, seat belts.
Agassiz-Harrison Community Services Society may refuse service or cease to provide service if a client has not fulfilled the eligibility requirements, has unpaid fees, or is abusive to volunteer drivers or AHCSS staff. Refusal to comply with AHCSS staff or Volunteer driver’s requests may result in a permanent termination of service.
Comments or Questions
I have read and understood the above guidelines*
Print Name
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