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Service Details

Service Type *

Booking Type

After-hours (+$0)Extended travel (+$15)

Contact Information

Full Name *

Phone Number *

Email Address

Vehicle Information

Year

Make

Model

Issue Description

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Location & Schedule

Service Location *

Preferred Date

Preferred Time

Liability Waiver

Roadguard Roadside Assistance Program, operates under The Burks Foundation, is not liable for pre-existing vehicle conditions, mechanical failures, or damages not directly caused by gross negligence. By accepting service, you agree to release the provider from liability related to unforeseen issues arising during or after service. All services are performed at the customer's request and risk.

I acknowledge and agree to the service terms and liability waiver. *

$25.00 deposit is charged now and applied toward your total. If you are a no-show (GOA), the deposit is forfeited. Remaining balance is due at time of service.

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