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About Us
Programs
Ways To Give
News & Updates
Contact

Wheels for Wellness Ride Checklist

Fill Out the Ride Checklist

Please fill out the below questionnaire. All questions with a red star are required. Comments can be left at the end but if anything is urgent please call 519-660-1430.

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1Information

2Driver Info

3Questions

4Questions

Thank you for completing ride. Please fill out the below questionaire. All questions with a red star are required. Comments can be left at the end but if anything is urgent 519-660-1430.

Driver Name *

First

Last

Client Name *

First

Last

Date *//

Ride Start Time *

Ride End Time *

Ride Location *

Is This Ride A Round Trip? *

Yes
No

Mask On *

Yes
No

Wiped Down All Shared Surfaces (door handles, seatbelt, tongue, buckles, surfaces that have been used by any other individuals in your vehicles) *

Yes
No

Hand Sanitizer Available *

Yes
No

Masks Available *

Yes
No

Backseat empty of unnecessary items *

Yes
No

Sign About The Spread Of Germs Available *

Yes
No

Wash Your Hands And/or Use Hand Sanitizer *

Yes
No

Wiped Down Barrier (If One In Place) And All Shared Surfaces *

Yes
No

Client Wore A Mask For The Entire Ride *

Yes
No

Dispose Of Mask (Or Put In For Washing) *

Yes
No

Did The Client Take A Mask From You? *

Yes
No

Additional Comments

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