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Ride the Road to Recovery Transportation Request Form

Our mission is to provide secure, safe and timely transportation needs to Surry County residents who require assistance in meeting and exceeding a healthier future.

After submitting this form and upon staff review a email or text message will be sent to you confirming your request.

If you have questions please contact Rebecca Dursee, Surry County Transportation Coordinator at 336-401-8266 or via email at Durseer@co.surry.nc.us

Transportation will not be provided on the following dates:

November 28 and 29, 2024

December 16, 2024

December 24, 25, and 26, 2024

January 1, 2025

Request Your Transportation Here!

Please take a moment to fill out the form.

First Name

Last Name

Email

Phone Number

Enter Your Pick Up Address

Additional Street Information

City

Region/State/Province

Postal / Zip code

What is Your Age?

Date of Birth

What is your sex?

Female

Male

Intersex

Prefer not to say

Are you a Veteran

Yes

No

Is This a Recurring Appointment?

Yes

No

Is this a One Way or Round Trip?

One Way Trip

Round Trip

First Appointment at service provider

Yes

No

Date of Appointment

Time of Appointment

Preferred Method of Communication

Call

Text

Other Information We Need to Know

I agree to the terms and conditions stated on this webpage. I also understand for routing and scheduling, submissions must be recieved two business days prior to the actual appointment date needed.

I understand that Ride the Road to Recovery is a no cost Rideshare Transportation Program. Rideshare programs like this, connect multiple people in one vehicle that travel together to the same or similar destination. While rider privacy and confidentiality are very important to the Ride the Road to Recovery Program and Staff, our program cannot assure anonymity and confidentiality. Please contact Ride the Road to Recovery Staff if you have concerns.

Reminder!!! If you chose Reoccurring Appointments please make sure to indicate the days you will need transportation assistance.

After submitting your Ride request, staff will contact you with any concerns and to confirm that we received your request. Your transportation request is not scheduled until you receive official confirmation from Ride to Recovery Staff.

Our staff strives to meet and exceed appointment requests, please do your part to be ready 1 hour prior to scheduled arrival times. We also take pride in a clean, safe environment for your comfort, we request that only water bottles are allowed during travel to and from destinations.

IMPORTANT: After submitting your request, a email receipt should be received within ten minutes from a no-reply email address. Please check your email account and/or spam folder for this email. If you do not see a receipt email your submission was not received. Call our office at 336-401-8266 for assistance.

Respuesta de opioides del condado de Surry

Scroll Down on this Webpage to Access Our Form!

Ride the Road to Recovery Transportation Request Form

Request Your Transportation Here!