Southeast Fort Wayne Grocery Rides - Community Transportation Network

Name*

First Last

Phone Number*

Email Address

Housing Complex*

Please select one of the housing complex options: Whispering Oaks, Southside Senior Villas, Tall Oaks, McCormick Place, or Miami Homes

Pick Up Date*

Whispering Oaks and Southside Senior Villas 1st Saturday of the month.

Prefered Pick Up Time*

Whispering Oaks and Southside Senior Villas pick up times available 8:30am, 9:30am, or 10:30am

Pick Up Date*

Tall Oaks 2nd Tuesday of the month.

Pick Up Date*

McCormick Place 3rd Tuesday of the month

Pick Up Date*

Miami Homes 4th Tuesday of the month

Prefered Pick Up Time*

Tall Oaks, McCormick Place, or Miami Homes pick up times available 6:30pm, 7:30pm, or 8:30pm

Number of Shoppers (including yourself)*

Max 2 people per family

Do you use a mobility aide?*

Type of mobility aide?*

Additional Information

To help us serve you better please answer the following questions. This section is not required .

Gender

Date of Birth

Ethnicity

Select one or more races that self-identify.

Consent*

I agree to the privacy policy.

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