Book Online Shuttle

First and Last Name *

Organization Name

Phone Number *

Email *

Trip Type - One-Time, Multiple Trips, Routine/Recurring Trip (enter all that apply) *

Trip Purpose: Medical-Related, Outing, Shopping Trip (enter all that apply) *

Trip Frequency: Daily, Weekly, Monthly (enter all that apply) *

Total Number of Passengers *

Total Number of Passengers Requiring Wheelchair Assistance *

Caregiver / Staff - list any additional individuals riding along *

Are any of the passengers under the age of 18? *

Mobility Aids & Stowable Items - Wheelchair, Walker, Cane, Crutches, Oxygen Tank, Collapsible Stroller (list all that apply) *

Pick Up Address *

Drop Off Address *

Wait Time *

No wait – Immediate pickup/drop-off only

Wait & Return (standby wait during appointment or errand)

Payment responsibility (customer, family member, nursing home etc.) *

Email to send invoice/payment confirmation to: *

How did you hear about us? If you were referred, please provide their name here. *

Opt-In: Yes, I would like a JewelRide staff member to contact me regarding my booking request.

Important: A JewelRide staff member must contact you to confirm the trip details, wait time, and payment method before your booking can be finalized. By proceeding, you authorize JewelRide to contact you.

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