Countywide Emergency Ride Home Application Application Agreement and Baseline Survey Name First Last Home Address Street Address City ZIP Code Home PhoneEmail Work Address Street Address City ZIP Code Work PhoneTo qualify for the Countywide ERH Program you must travel to work at least one day a week by: bus, carpool, vanpool, bicycle, electric bicycle, or walking, and you must agree to complete one follow-up survey within a year. This baseline survey is to help the Ecology Action establish commuter habits of Santa Cruz County residents. All information will remain anonymous. I plan to use the following travel methods to get to work in the upcoming year (put estimated number of days per week):Drive aloneBusCarpoolVanpoolBicycleWalkTelecommuteOtherDescribeHow many miles is it from your home to work?How many days a week do you normally drive alone to work?What obstacles prevent you from using an alternative mode of transportation more often to commute to work? What if a family member or I got sick, and I had to leave work? What if a family member or I had an emergency, and I had to leave work? What if I am asked by my supervisor to work late and I missed my ride? What if my carpool driver had to leave early or stay late? What if my bike or electric bike broke down or got stolen? Please add any other reasons that prevent you from using an alternative mode of transportation more often for your daily work commute.:Because of the Emergency Ride Home Program will you use an alternative mode of transportation more often to commute to work? Yes Have you previously registered with 511.org? Yes No Is your employer a member of Ecology Action’s Transportation Services? Yes No Unsure Please read the following carefully: Participant Agreement: I understand the guidelines of the Emergency Ride Home Program and qualify by traveling to work at least one day per week using an alternative mode of transportation. I understand that the vouchers are non-transferable, and that the vouchers are to be used during work hours, and only on days when I have used an alternative mode of transportation for my commute. I agree to complete one follow up survey within a year of the date the voucher is issued to me, whether or not I use the voucher. Program is subject to end due to limited funds. By clicking the "Send Now" button, I agree to comply with the conditions of this program and hereby release Ecology Action from any liability, claims, and demands for personal injury, loss, theft, or damage to my personal property; loss of income, consequential damage resulting from delays or absence of a taxi cab, or termination of the program.EmailThis field is for validation purposes and should be left unchanged.