Transportation Program | ALS United Orange County

ALS United Orange County provides $75 transportation vouchers each way to ALS patients to and from medical appointments. If you need a voucher, please fill out the form below. Questions? Email info@alsuoc.org or call/text 714-285-1088.

Transportation Voucher

* Transportation requests require a minimum of 5 business days to process. Rides within Orange County only.

Name(Required)

First Last

Phone(Required)

Email(Required)

Enter Email Confirm Email

Transportation Date(Required)

Pick-Up Time(Required)

Pick-Up Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Destination Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Type of Medical Appointment(Required)

Type of Wheelchair(Required)

Standard Wheelchair

High Back Reclining Chair

Name of accompanying Caregiver(Required)

Caregiver's Phone(Required)

Please check box acknowledging that requestor understands and accepts responsibility for any fees exceeding $75 one way. (Total $150 per trip)(Required)

I accept