Rides for Henry County Health Center

Question Title

* 1. In the last 2 months, did you have problems getting to the following:

Doctor Appointment

Pharmacy

Grocery Store

Childcare drop off or pick up

a Job

Job Interview

Social Service Appointment

court appointment

local bank

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* 2. Do you have children that travel with you often? If yes, please mark below.

0-2 years old

3-5 years old

6-13 years old

14 years old and older

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* 3. Have you had to cancel an appointment in the past 12 months due to the following ?

never could get a ride

had a ride but they canceled on me

my car broke down

I live nearby by and planned to walk but the weather was bad that day.

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* 4. If Henry County Health Center offered same day transportation for any healthcare appointment, would you be able to donate the following?

$1 per ride

$2 per ride

$2.50 per ride

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* 5. If you would like to be entered into a drawing, for filling out the survey, enter your first and last name with your phone number below.