Request a Ride

We are now accepting applications through Jul 9, 2026

Complete the application below to request a ride.

For all questions, please call (205) 978-1000 OR 1-800-543-7143

Request a Ride - English

Step 1 of 2

Client Information

Is the Client

If expecting, what is the due date?

What is the transportation need?

Type of Health Insurance

Client Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Home Phone

Client or Guardian Cell Phone

Client or Guardian Email Address

Client Date of Birth

Race/Ethnicity (select all that apply)

Black

White

Hispanic

Asian

Other

Gender

Parent/Guardian Contact Name (if applicable)

First Last

Relationship to the client:

Guardian Phone Number

Referrer Information

Referring Party's Name

First Last

Referring Agency (if applicable)

Referring Party's Email Address

Referring Party's Phone

Trip Information

Date of Appointment

Appointment Time

Treating Facility/Agency Name

Address

Street Address Address Line 2 City State ZIP Code

Office Phone Number

Treating Facility/Agency Email Address

Doctor or Therapist Name

First Last

Number of Passengers

Please enter a number from 1 to 9.

Before scheduling this appointment please make sure the client will follow through in keeping this appointment with Kid One. Held space cancelled at the last minute prevents other children from accessing our much needed service and may jeopardize the client’s ability to access Kid One services.