off-site trip REQUEST

This form should be completed whenever residents in Assisted Living, MyTapestry or the Healthcare Center would like to leave campus for medical or non-medical outings.
This form must be completed at least 48 hours prior to the outing.

* All fields and answers are required:

Time of Outing

I am requesting that Luther Oaks provide this transportation.

Select an option

If YES, Luther Oaks to provide this transportation.

All trips off-campus must comply with the following expectations. The resident will be evaluated upon return from the outing. If the resident shows any signs or symptoms of COVID-19 or if any of the below conditions were not maintained, the resident may be placed on quarantine precautions for 14 days upon return.

 

Please carefully review the following expectations during outing:

  1. Resident and those assisting them are to perform frequent hand-hygiene while at the destination

  2. Resident and those with whom they come in contact will continuously wear a face covering

  3. Resident is to maintain six feet of separation from other individuals while at destination

Thank you.
Your request has been delivered.