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to setup or return to your account for this form. Creating an account enables you to return to this form and your submitted results. An account will also enable you to partially complete this form and return later to finish the form. The account you establish is only for this form. When setting up accounts for the form, we ask for an email address. This email address will only be used to provide you with login details and for recovering lost username/password combinations. NO SPAM!
SafeRide Service Reservation Request
Fill in the information below to request a reservation for a team of SafeRide America drivers to drive you and your car home for you. Please give us as much detail as possible.
We will either call or email you a confirmation.
If after submiting this reservation you would like to make changes to any detail please call us at 404-888-0887.
Although you must use a credit card to hold this reservation you can pay with the card or in cash without having anything billed to your card.
Name & Contact Information
*
First Name
*
Last Name
*
Email Address
*
Phone
*
Are you a member?
Yes
No
Pick-up Details
*
Are we picking you up from a business or a residence?
Business
Residence
What is the name of the business, sub-division or apartment complex?
Pick-up Street Address
Address Line 2
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
Pick-up Location Phone Number
(Optional)
*
Number of people in your party
Reservation Type
*
Select type of reservation. (Select one)
FIRM Reservation (For a set specific time)
FLEX Reservation (This is for when you are not exactly sure when you want to be picked up. This option allows for a two hour window of time and you must call at least one hour before you want to be picked up.)
Enter FIRM Reservation Details Here
SafeRide Service Pick-up Date
If the pick-up time is not listed below, that means we are booked for that time.
Firm Pick-up Time
12:00 AM (Midnight)
12:15 AM
12:30 AM
12:45 AM
1:00 AM
1:15 AM
1:30 AM
1:45 AM
2:00 AM
2:15 AM
2:30 AM
2:45 AM
3:00 AM
3:15 AM
3:30 AM
3:45 AM
4:00 AM
4:15 AM
4:30 AM
4:45 AM
5:00 AM
5:15 AM
5:30 AM
5:45 AM
6:00 AM
6:15 AM
6:30 AM
6:45 AM
7:00 AM
7:15 AM
7:30 AM
7:45 AM
8:00 AM
8:15 AM
8:30 AM
8:45 AM
9:00 AM
9:15 AM
9:30 AM
9:45 AM
10:00 AM
10:15 AM
10:30 AM
10:45 AM
11:00 AM
11:15 AM
11:30 AM
11:45 AM
12:00 PM (Noon)
12:15 PM
12:30 PM
12:45 PM
1:00 PM
1:15 PM
1:30 PM
1:45 PM
2:00 PM
2:15 PM
2:30 PM
2:45 PM
3:00 PM
3:15 PM
3:30 PM
3:45 PM
4:00 PM
4:15 PM
4:30 PM
4:45 PM
5:00 PM
5:15 PM
5:30 PM
5:45 PM
6:00 PM
6:15 PM
6:30 PM
6:45 PM
7:00 PM
7:15 PM
7:30 PM
7:45 PM
8:00 PM
8:15 PM
8:30 PM
8:45 PM
9:00 PM
9:15 PM
9:30 PM
9:45 PM
10:00 PM
10:15 PM
10:30 PM
10:45 PM
11:00 PM
11:15 PM
11:30 PM
11:45 PM
Enter FLEX Reservation Details Here
SafeRide Service Pick-up Date
Earliest Pick-up Time
12:00 AM (Midnight)
12:15 AM
12:30 AM
12:45 AM
1:00 AM
1:15 AM
1:30 AM
1:45 AM
2:00 AM
2:15 AM
2:30 AM
2:45 AM
3:00 AM
3:15 AM
3:30 AM
3:45 AM
4:00 AM
4:15 AM
4:30 AM
4:45 AM
5:00 AM
5:15 AM
5:30 AM
5:45 AM
6:00 AM
6:15 AM
6:30 AM
6:45 AM
7:00 AM
7:15 AM
7:30 AM
7:45 AM
8:00 AM
8:15 AM
8:30 AM
8:45 AM
9:00 AM
9:15 AM
9:30 AM
9:45 AM
10:00 AM
10:15 AM
10:30 AM
10:45 AM
11:00 AM
11:15 AM
11:30 AM
11:45 AM
12:00 PM (Noon)
12:15 PM
12:30 PM
12:45 PM
1:00 PM
1:15 PM
1:30 PM
1:45 PM
2:00 PM
2:15 PM
2:30 PM
2:45 PM
3:00 PM
3:15 PM
3:30 PM
3:45 PM
4:00 PM
4:15 PM
4:30 PM
4:45 PM
5:00 PM
5:15 PM
5:30 PM
5:45 PM
6:00 PM
6:15 PM
6:30 PM
6:45 PM
7:00 PM
7:15 PM
7:30 PM
7:45 PM
8:00 PM
8:15 PM
8:30 PM
8:45 PM
9:00 PM
9:15 PM
9:30 PM
9:45 PM
10:00 PM
10:15 PM
10:30 PM
10:45 PM
11:00 PM
11:15 PM
11:30 PM
11:45 PM
Latest Pick-up Time
12:00 AM (Midnight)
12:15 AM
12:30 AM
12:45 AM
1:00 AM
1:15 AM
1:30 AM
1:45 AM
2:00 AM
2:15 AM
2:30 AM
2:45 AM
3:00 AM
3:15 AM
3:30 AM
3:45 AM
4:00 AM
4:15 AM
4:30 AM
4:45 AM
5:00 AM
5:15 AM
5:30 AM
5:45 AM
6:00 AM
6:15 AM
6:30 AM
6:45 AM
7:00 AM
7:15 AM
7:30 AM
7:45 AM
8:00 AM
8:15 AM
8:30 AM
8:45 AM
9:00 AM
9:15 AM
9:30 AM
9:45 AM
10:00 AM
10:15 AM
10:30 AM
10:45 AM
11:00 AM
11:15 AM
11:30 AM
11:45 AM
12:00 PM (Noon)
12:15 PM
12:30 PM
12:45 PM
1:00 PM
1:15 PM
1:30 PM
1:45 PM
2:00 PM
2:15 PM
2:30 PM
2:45 PM
3:00 PM
3:15 PM
3:30 PM
3:45 PM
4:00 PM
4:15 PM
4:30 PM
4:45 PM
5:00 PM
5:15 PM
5:30 PM
5:45 PM
6:00 PM
6:15 PM
6:30 PM
6:45 PM
7:00 PM
7:15 PM
7:30 PM
7:45 PM
8:00 PM
8:15 PM
8:30 PM
8:45 PM
9:00 PM
9:15 PM
9:30 PM
9:45 PM
10:00 PM
10:15 PM
10:30 PM
10:45 PM
11:00 PM
11:15 PM
11:30 PM
11:45 PM
To insure a prompt pick-up time, I acknowledge and understand that I must call 404-888-0887 at least one-hour before I want to be picked up.
Pick-up Details
*
What kind of car will we be driving? Enter the make and model.
*
What color is the car?
Black
White
Gray/Silver
Light Blue
Dark Blue
Red/Burgundy
Green
Yellow/Gold
Orange
Brown/Beige
Purple
Other
*
Type of transmission
Automatic
Manual (Stick shift)
Special Instructions
Drop-off Details
Street Address
Address Line 2
*
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
SafeRide Driver Request
*
If you prefer to have a particular driver, enter their name here, if not enter none.
SafeRide Service Rates
The basic rate for SafeRide Service is
$20 pick-up fee plus $2.50 per mile, plus tip to the drivers
If picked up from a sponsoring location or a members home
$15 pick-up fee plus $2.50 per mile, plus tip to the drivers
CLICK HERE
to see a list of sponsoring locations
If you are a Project 21 Member
$10 pick-up fee plus $2.50 per mile, plus tip to the drivers
CLICK HERE
to learn how to become a Project 21 Member
*
Choose the rate that applies to you (Rate chosen will be verified and adjusted if necessary)
$20 pick-up fee, plus $2.50 per mile, plus tip to the drivers (Non-Member/Non-Sponsoring Location)
$15 pick-up fee, plus $2.50 per mile, plus tip to the drivers(Member/Non-Sponsoring Location or Non-Member/Sponsoring Location))
$10 pick-up fee, plus $2.50 per mile, plus tip to the drivers (Member/Sponsoring Location)
Unsure? Please contact us to discuss the rate.
Credit Card Information
Name on Card
Credit Card Type
Visa
MasterCard
American Express
Discover
Credit Card Number
Expiration Date (mm/yy)
CSC Code
Billing Zip Code
*
Indicates Response Required