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2. Carpool Rider Information

4. First Name*
5. Last Name*
7. Zone number

   Choose the Zone (number) from the map below corresponding to your address, or where you would like to be picked up.

   Exact information of pick up will be given out at your discretion during your communication with a volunteer driver.

   *The Peck Center is not directly involved in scheduling rides.

9. Map of Barrington Carpool Zones
   
11. Phone Number
12. Email Address
14. Preferred Contact Method

    1. Phone
    2. Text
    3. Email

16. Fill in times for any days you would like a ride, leave blank if you do not need a ride on that day. 

    (Example: 8:30-9:00 AM)

18. Monday - Preferred Pickup Time Window
19. Monday - Return Time Window
21. Tuesday - Preferred Pickup Time Window
22. Tuesday - Return Time Window
24. Wednesday - Preferred Pickup Time Window
25. Wednesday - Return Time Window
27. Thursday - Preferred Pickup Time Window
28. Thursday - Return Time Window
30. Friday - Preferred Pickup Time Window
31. Friday - Return Time Window

33. Mobility & Accessibility

35. Mobility Aids

    1. None
    2. Cane
    3. Walker
    4. Folding wheelchair
    5. Other
36. Need help entering/exiting vehicle?

    1. Yes
    2. No
38. Consent & Acknowledgment

    • This is a completely volunteer-based program, no guarantee of rides are given.

    • Your phone number and email address will be posted on the carpool volunteer webpage.

    • By submitting this form, you are giving permission to be contacted by volunteer drivers.

    • To change the dates or times you would like to be picked up, resubmit a new carpool form.

    • If you would like to stop receiving calls/emails, submit this form with just your first and last name (leave all other information blank).

Leave This Blank:


40. 1. Receive an email copy of this form.
41. Email address

    This field is not part of the form submission.

42. Submit

* indicates a required field