The Epilepsy Foundation Of Delaware


EFDE Transportation Program
EFDE is excited to offer our new transportation program!
Guidelines and Qualifications:
-Must live in Delaware.
-Must have an epilepsy/seizure disorder diagnosis and a neurologist.
-One way trips may be no longer than 15 miles in length and must start and end in Delaware.
-One round trip ride permitted per week.
-Must be able to enter and exit the vehicle on your own without help.
-Must be 18 or older.
-Two persons in addition to the person with epilepsy can ride (maximum three people).
*Rides are provided by Uber Health and must be scheduled through EFDE at least 2 business days prior to the scheduled ride. If you are interested in signing up for this program please complete and submit this form. You will receive a follow up call to confirm your information and set up your account.
First Name *
Last Name *
Birth Date *	// (mm/dd/yyyy)
Address 1
Address 2
City
State/Province
Zip
Phone Type
Phone *
Email *
What is the date of when you were first diagnosed with epilepsy? *
Please enter the name and phone number of your neurologist. *
Are you able to get in and out of a vehicle by yourself? (The driver is not allowed to assist.) *
Were you advised by your neurologist not to drive? (This if for internal purposes only. It will NOT affect your eligibility.) *
How did you learn about the program?
If you would like to add a trusted contact for your trip, enter first and last name and phone number:

Timeout Warning