Access Shuttle Form

Rider Information

Name *

First and Last Name

Email *

Verify Email *

Phone Number *

Enter a phone number where you can be reached.

Adaptive Equipment Used

Additional information

Pickup Schedule

Start Date *

Month MonthJanFebMarAprMayJunJulAugSepOctNovDec

Day Day12345678910111213141516171819202122232425262728293031

Year Year20222023202420252026

Enter the date you need rides to start. If you need a ride today, please call the access shuttle phone at 541-852-2561.

End Date *

Month MonthJanFebMarAprMayJunJulAugSepOctNovDec

Day Day12345678910111213141516171819202122232425262728293031

Year Year20222023202420252026

The last day you will need a ride on the current schedule.

Days of the Week *

Monday

Tuesday

Wednesday

Thursday

Friday

Please enter the days if the week that you will need a ride for.

Monday Schedule

First Ride

First Pickup Location *

First Pick Up Time *

Hour Hour123456789101112

:

Minute Minute000510152025303540455055

am

pm

First Drop Off Location *

Time You Need To Be At The Destination *

Hour Hour123456789101112

:

Minute Minute000510152025303540455055

am

pm

Second Ride

Second Pickup Location

Second Pick Up Time

Hour Hour123456789101112

:

Minute Minute000510152025303540455055

am

pm

Second Drop Off Location

Time You Need To Be At The Destination

Hour Hour123456789101112

:

Minute Minute000510152025303540455055

am

pm

Third Ride

Third Pickup Location

Third Pick Up Time

Hour Hour123456789101112

:

Minute Minute000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859

am

pm

Third Drop Off Location

Time You Need To Be At The Destination

Hour Hour123456789101112

:

Minute Minute000510152025303540455055

am

pm

Fourth Ride

Fourth Pickup Location

Fourth Pick Up Time

Hour Hour123456789101112

:

Minute Minute000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859

am

pm

Fourth Drop Off Location

Time You Need To Be At The Destination

Hour Hour123456789101112

:

Minute Minute000510152025303540455055

am

pm

Tuesday Schedule

First Ride

First Pickup Location *

First Pick Up Time *

Hour Hour123456789101112

:

Minute Minute000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859

am

pm

First Drop Off Location *

Time You Need To Be At The Destination *

Hour Hour123456789101112

:

Minute Minute000510152025303540455055

am

pm

Second Ride

Second Pickup Location

Second Pick Up Time

Hour Hour123456789101112

:

Minute Minute000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859

am

pm

Second Drop Off Location

Time You Need To Be At The Destination

Hour Hour123456789101112

:

Minute Minute000510152025303540455055

am

pm

Third Ride

Third Pickup Location

Third Pick Up Time

Hour Hour123456789101112

:

Minute Minute000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859

am

pm

Third Drop Off Location

Time You Need To Be At The Destination

Hour Hour123456789101112

:

Minute Minute000510152025303540455055

am

pm

Fourth Ride

Fourth Pickup Location

Fourth Pick Up Time

Hour Hour123456789101112

:

Minute Minute000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859

am

pm

Fourth Drop Off Location

Time You Need To Be At The Destination

Hour Hour123456789101112

:

Minute Minute000510152025303540455055

am

pm

Wednesday Schedule

First Ride

First Pickup Location *

First Pick Up Time *

Hour Hour123456789101112

:

Minute Minute000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859

am

pm

First Drop Off Location *

Time You Need To Be At The Destination *

Hour Hour123456789101112

:

Minute Minute000510152025303540455055

am

pm

Second Ride

Second Pickup Location

Second Pick Up Time

Hour Hour123456789101112

:

Minute Minute000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859

am

pm

Second Drop Off Location

Time You Need To Be At The Destination

Hour Hour123456789101112

:

Minute Minute000510152025303540455055

am

pm

Third Ride

Third Pickup Location

Third Pick Up Time

Hour Hour123456789101112

:

Minute Minute000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859

am

pm

Third Drop Off Location

Time You Need To Be At The Destination

Hour Hour123456789101112

:

Minute Minute000510152025303540455055

am

pm

Fourth Ride

Fourth Pickup Location

Fourth Pick Up Time

Hour Hour123456789101112

:

Minute Minute000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859

am

pm

Fourth Drop Off Location

Time You Need To Be At The Destination

Hour Hour123456789101112

:

Minute Minute000510152025303540455055

am

pm

Thursday Schedule

First Ride

First Pickup Location *

First Pick Up Time *

Hour Hour123456789101112

:

Minute Minute000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859

am

pm

First Drop Off Location *

Time You Need To Be At The Destination *

Hour Hour123456789101112

:

Minute Minute000510152025303540455055

am

pm

Second Ride

Second Pickup Location

Second Pick Up Time

Hour Hour123456789101112

:

Minute Minute000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859

am

pm

Second Drop Off Location

Time You Need To Be At The Destination

Hour Hour123456789101112

:

Minute Minute000510152025303540455055

am

pm

Third Ride

Third Pickup Location

Third Pick Up Time

Hour Hour123456789101112

:

Minute Minute000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859

am

pm

Third Drop Off Location

Time You Need To Be At The Destination

Hour Hour123456789101112

:

Minute Minute000510152025303540455055

am

pm

Fourth Ride

Fourth Pickup Location

Fourth Pick Up Time

Hour Hour123456789101112

:

Minute Minute000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859

am

pm

Fourth Drop Off Location

Time You Need To Be At The Destination

Hour Hour01234567891011121314151617181920212223

:

Minute Minute000510152025303540455055

Friday Schedule

First Ride

First Pickup Location *

First Pick Up Time *

Hour Hour123456789101112

:

Minute Minute000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859

am

pm

First Drop Off Location *

Time You Need To Be At The Destination *

Hour Hour123456789101112

:

Minute Minute000510152025303540455055

am

pm

Second Ride

Second Pickup Location

Second Pick Up Time

Hour Hour123456789101112

:

Minute Minute000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859

am

pm

Second Drop Off Location

Time You Need To Be At The Destination

Hour Hour123456789101112

:

Minute Minute000510152025303540455055

am

pm

Third Ride

Third Pickup Location

Third Pick Up Time

Hour Hour123456789101112

:

Minute Minute000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859

am

pm

Third Drop Off Location

Time You Need To Be At The Destination

Hour Hour123456789101112

:

Minute Minute000510152025303540455055

am

pm

Fourth Ride

Fourth Pickup Location

Fourth Pick Up Time

Hour Hour123456789101112

:

Minute Minute000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859

am

pm

Fourth Drop Off Location

Time You Need To Be At The Destination

Hour Hour123456789101112

:

Minute Minute000510152025303540455055

am

pm