Organisation Referral Form

Rides to Hope
Organisation Application

Use this form to refer a client or group for free or subsidised transport through the Rides to Hope program, delivered by Safe Transport Australia via the Shebah platform.

This form takes approximately 5–10 minutes to complete.

🔒 Client privacy is our priority All client information is kept strictly confidential. If your client requires anonymity, you may use an identifier instead of their name. Please only share what is necessary and safe.

Section 1 of 4

Organisation Information

Tell us about your organisation and the person submitting this referral.

Organisation Name * Please enter your organisation name

Charity Registration Number If applicable

Contact Person * Please enter the contact person's name

Role within Organisation * Please enter your role

Phone Number * Please enter a phone number

Email Address * Please enter an email address

Has your organisation previously partnered with Rides to Hope or Shebah? *

Yes No

Please select an option

Section 2 of 4

Client Information

Tell us about the client or group you are referring. Use an identifier if the client requires anonymity.

Number of People Requiring the Trip *

Individual Group

Please select an option

Number of people in group * Maximum 6 people per trip

Client Name(s) or Identifier * Use an identifier (e.g. "Client A") if anonymity is required Please enter client name or identifier

Client Age(s) * Please enter client age(s)

Client Contact Number * Please provide one number to be contacted regarding the trip Please enter a contact number for the client

Primary Reason for Needing Support * e.g. financial hardship, domestic violence, disability Please provide the primary reason for support

Does the client or anyone in their group face mobility or accessibility challenges? *

Yes No

Please select an option

Please specify the accessibility requirements

Is the client currently receiving any government or community financial support? *

Yes No Unknown

Please select an option

Does the client or group have access to a personal vehicle or alternative transport? *

Yes No

Please select an option

Section 3 of 4

Trip Details

Provide the details of the trip you are requesting for your client.

Date and Time of Trip * Please provide the trip date and time

Pickup Location * Full street address Please enter a pickup address

Destination * Full street address Please enter a destination address

Safety notes regarding pickup * e.g. wait down the road and message when arrived; remove Shebah decals Please enter safety notes or write "none"

Purpose of the Trip * e.g. medical appointment, school pickup, court appearance Please enter the purpose of the trip

Will any ride extras be required? *

Yes No

Please select an option

Baby seat (infant, 0–6 months) Child car seat (toddler, 6 months–4 years) Booster seat (4–8 years) Wheelchair accessible vehicle Extra luggage space

Further requests for the driver e.g. no music in car, no talking, prefer quiet trip

Section 4 of 4

Charity Endorsement & Consent

Please confirm your endorsement of this client's eligibility and agree to the declarations below.

Based on your knowledge, does this client meet the Rides to Hope criteria for discounted fares due to financial hardship or vulnerability? *

Yes No

Please select an option

Further information or supporting evidence Optional — any additional context to support this application

✅

Referral Submitted

Thank you for referring your client. A member of the Rides to Hope team will be in touch with you shortly to confirm the trip details.

If this is an urgent matter, please contact Safe Transport Australia directly.

Rides to HopeOrganisation Application

Referral Submitted

Rides to Hope
Organisation Application