Wheels for Wellness Ride Checklist Fill Out the Ride Checklist Please fill out the below questionnaire. All questions with a red star are required. Download Printable Copy Please enable JavaScript in your browser to complete this form.1Information2Driver Info3Questions4QuestionsThank you for completing this ride! Please fill out the below questionnaire. All questions with a red star are required. NextDriver Name *FirstLastClient Name *FirstLastDate of Ride *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Pick Up Time *Home Drop Off Time *Feedback Notes *PreviousNextDid you sanitize your vehicle prior to ride? *YesNoDid client wear mask for the entire ride? *YesNoDid you wear a mask the entire ride? *YesNoWas the client ready when you arrived? *YesNoDid the client need excessive assistance when entering or exiting the vehicle? *YesNoWas ride completed within time frame of request? *YesNoPreviousNextSubmit
