Approximately how long has it been since you have used any form of public transportation? *
Choose
Less than a week
1-2 weeks
2-4 weeks
1-2 months
More than 2 months
Approximately how long has it been since you have visited a high risk zone in the US (e.g. Boston, Washington State, New York City)? *
Choose
Less than a week
1-2 weeks
2-4 weeks
1-2 months
More than 2 months
Have you been in contact with anyone with a confirmed case of COVID-19 or showing symptoms of COVID-19? *
Are you exhibiting any of the confirmed COVID-19 symptoms (e.g. cough, headache, fever, shortness of breath) consistent with NIH guidelines? *
What services would you be able to provide? *
Required
Full Name *
Your answer
Town/City of Residence
Your answer
Maximum time from home willing to deliver (one-way)? *
Choose
5 minutes
10 minutes
15 minutes
20 minutes
30 minutes
Greater than 30 min
Phone Number *
Your answer
Type of Vehicle *
Choose
Hatchback
Truck
Wagon
Sedan
SUV
Other
Do you have insurance on your vehicle? *
Do you have a clean driving record (no moving violations) for the past 5 years? *
After you submit this form, you will be asked to submit a photo of your driver's license to keenehelpers@gmail.com (for our insurance purposes). Please briefly explain a "No" answer to this question when you send in your license.