Request a Ride

Tell us about the ride you need

Complete the form below, or call LifeLink to speak with our team. We'll review your request and follow up to discuss availability, assistance needs, and next steps.

Submitting this form does not confirm a ride. LifeLink will contact you before arrangements are confirmed.

01Your contact details

We'll use these to follow up about the trip.

Your name

Phone number

Email address

I'm requesting a ride for:

Myself Someone else

02Trip details

If you're not sure about something, leave it blank. We'll talk it through with you.

Ride type

Ambulatory Wheelchair Recurring I'm not sure

Pickup location

Destination

Requested date and time

Is a return ride needed?

Yes No I'm not sure

Days and times of regular appointments

A recurring request starts a conversation with our team; it does not automatically reserve future rides.

03Assistance needs

Briefly tell us what transportation assistance the rider needs.

Assistance needs

Please do not include diagnoses or other detailed medical information in this form.

By submitting, you agree to our Privacy Policy.

Thank you.

We received your request and will contact you to discuss availability. Your ride is not yet confirmed.

Back to home Call (717) 790-5465

Tell us about the ride you need

Ride request form

Thank you.