Request Access

Free Medical Transportation Services

Name *

Phone *

Email *

Primary Passenger Information

Passenger Name *

First

Last

Use Full Legal Name as appears on your ID Card

Email *

Confirm Email

Home Phone *

Cell Phone *

Street Address *

City *

State

Zip code *

Date of Birth *

Patient's Military Status *

Gender *

Travel Information

Please complete as much detail as possible about the Primary Passengers Travel request.

Appointment Date *

Select Appt Time *

Do you require wheelchair assistance? *

Is the driver of the vehicle properly licensed and insured? *

How many trips will be required for your treatment?* *

Please explain your travel plans/needs in detail below. *

Transportation mode

Are you requesting a donated gas card, or a donated Amtrak/Greyhound Bus ticket? Please select your preference below: *

Facility to which you are traveling

Name of Treatment Facility at Destination *

Street Address *

City *

State

Zip code *

Caregiver Information

If you are traveling with a caregiver, please complete the following (all fields required if traveling with a caregiver).

First Name

Last Name

Gender

Date of Birth

Relationship to Passenger

Screening Information

As each trip is a gift from a donor, it is important for us to understand the financial need and reason for requesting assistance. Please fill out a brief description in each box and answer the questions below to help us help you.

Select how did you hear about Us? *

Patient's primary illness/condition (briefly) *

Select illness Category *

Financial Situation *

Brief description of financial situation that warrants support

Reason for travel *

Brief description of passenger's illness, diagnosis, or reason for needing assistance

Income & Appointment Verification

Please upload documentation verifying that you have a medical appointment at the facility specified above *

Examples include a letter from you physician, a printed appointment reminder from the physician's office, or a screen shot of the appointment details from your online patient portal. Please note that the documentation must include your name.

Please upload documentation showing your household income.

Examples include your most recent federal tax return, 3 months of bank statements, proof of Medicaid or EBT/SNAP benefits. We do not accept pay stubs or W2s as sole proof of income. We may request additional documentation in order to verify household income. Be sure to black out all social security numbers on your documents.

Please provide us with a photo of yourself.

We use these photos in our fundraising and promotional efforts, so passenger photos are a very important way for us to continue offering these free services. Thank you for your assistance!

Likeness Release Form

Please read carefully and agree to the Likeness Release Form for your photo:

I hereby grant all rights to Healing Journey Medical Transportation. hereafter referred to as Companies permission to use my likeness in a photograph, video or in any and all of its publications and materials including website entries, advertisements, emails, marketing material, photo’s, Images, videos, ads, marketing, print, material, online marketing, search engine marketing and optimization, digital marketing, and/or any and all forms of printable documents.
I as the Parent, Student, Model and/or Employee acknowledges that there will be no compensation or any other consideration and fully assigns all rights of said likeness to companies, its officers, and assigned agents both now and forever and agree to hold harmless said companies and additionally, individuals, companies, businesses, or corporations that have been or are now clients of Healing Journey Medical Transportation.
Rights Granted to Companies and its Officers:
I understand and agree that these materials will become the property of the Companies while giving full rights and authorization to utilize my likeness.
I hereby irrevocably grant the Companies the absolute right and permission, in its broadest sense, to use and reuse (or to refrain from any such use), including to copyright, trademark, publish, republish, reproduce, broadcast, digitize, alter or any other present or future method of communication, reproduction or use (collectively "Use"), any and all photographs, digital or video images, drawings or renderings, video reproductions, name and likeness of myself and of his property (clothes, jewelry, glasses, etc.) and/or personal information provided to Companies, in whole or in part, in conjunction with or without my own name, or any material based thereon or derived from any of the foregoing (collectively "Materials"), in any present or future manner or media of communication whatsoever including, but not limited to, print, digital media, marketing of all kinds, television, advertising, promotional, publicity, Internet, trade, editorial or other means, throughout the universe, in perpetuity.
No Inspection or Additional Compensation:
I hereby waive any right that I may have to inspect or approve any Use of the Materials or any advertising or promotional copy or other printed matter that may be used in connection with any advertising or promotional copy or other printed matter that may be used in connection with or derived from the Materials. I also acknowledge and agree that I am not entitled to any additional payment or other compensation for the above- stated Use of the Materials and I hereby wave any present and/or future claim for any such payment or compensation. I understand that the Companies may alter the Materials, either intentionally or unintentionally, by virtue of blurring, distortion, alteration, optical illusion, use in a composite form or other methods.
Materials Owned by Companies:
I agree that the Materials and anything derived from the Materials are owned solely by Companies. All value and goodwill arising from the Materials or the Companies Use of the Materials, shall accrue solely to the Companies and its assigns for use as it see fit. I will not authorize the use of the Materials by anyone else without the Companies advance, written approval as I do not own said rights of any image, photo, picture, video, likeness or any such materials.
Release of Privacy Rights and Related Claims:
I hereby irrevocably release Companies from any and all claims or liability, known or unknown, of any nature or kind, including, without limitation, claims for invasion of any personal or property right which I may have, or which his heirs, executors, administrators and assigns hereafter may have, including without limitation, claims based upon invasion of privacy, defamation, false light, commercial appropriation or use of name, likeness, video, voice or picture, emotional distress, right of publicity or copyright, for any matter whatsoever arising out of the Use of the Materials, including reasonable editing of written personal information provided to Companies by me.
Entire Agreement:
This document represents the entire agreement between the parties and may only be modified in writing and signed by all parties hereto. This marketing release is governed by the internal laws of the Commonwealth of Virginia, USA, without regard to its choice of law principles contained therein. I hereby irrevocably authorize the Companies to edit, alter, copy, exhibit, publish or distribute this photo for purposes of publicizing and marketing of the Companies programs or for any other lawful purpose. In addition, I waive the right to inspect or approve the finished product, including written or electronic copy, wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photograph. I hereby truthfully waive any and all rights to my likeness, image, and/or photograph, and fully understand the above mentioned companies own all rights to said likeness.

I agree to the terms of the Likeness Release Form: *

Please choose the income bracket that best represents the patient's total, annual, household family income *

Please the number of people living in your household. *

Please choose the ethnicity that best describes the patient. *

Name