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Online Transportation Intake Form
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* Indicates required question
First / Last Name
*
Your answer
Date of Birth
*
Your answer
Physical and Mailing Address
*
Your answer
e-mail address
Your answer
Main Contact Number
*
Your answer
When would be the best time to contact you>
*
Morning
Afternoon
e-mail only
Do you have a Valid Driver's License?
*
Yes
No
Other:
How did you hear about us?
*
Family/Friend
HCEOC Employee
Website/Social Media
Government Agency
Non- Profit Organization
Medical Office/Hospital
Required
What is your current form of transportation (select all that applies)
*
Drive a vehicle
Hele-On Bus Services
Hele- On Kako'o Paratransit Service
County of Hawaii - Office of Aging
Medical Taxi
Taxi, Uber, Lyft
Family/Friends
Other:
Required
Please list your transportation needs ( (select all that applies)
*
Access to Hele- On Bus Stop Locations
Medical Appointments
Essential Services - Shopping, Banking , Errands
Adult Care Facilities
Rehabilitation Centers
Other:
Required
Do you require any of the following accommodations (select all that applies)
*
Vehicle with a Ramp/Lift
Wheel Chair Accessible Vehicle
Service Animal / Comfort Animal
Personal Care Attendant
Not Applicable
Other:
Required
Questions and comments
Your answer
Submit
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