Transportation Programs

RideSurance Registration Application

Please fill out the form below to register for the RideSurance Program. After your application is sumbited you will be directed to pay a $24.00 application fee online (PayPal). This fee must be paid before your application process is complete.

Application Agreement and Baseline Survey

Your Name
Your Home Address
Home City
State
Zip Code
Home Phone
Your Email
Your Employer (Company)
Your Work Address
Work City
State
Zip
Work Phone
Supervisor's Name
Supervisor's Phone

Membership to RideSurance is a $24.00 annual fee. To qualify for RideSurance you must travel to work at least one day a week by bus, carpool, vanpool, bicycle, electric bicycle, or walking. Additionally you must agree to complete one follow-up survey within a year. This baseline survey is to help establish commuter habits of Santa Cruz County residents. All information submitted in this baseline survey will remain anonymous. 1) I plan to use the following travel methods to get to work in the upcoming year (put estimated number of days per week):
Drive Alone	days per week
Bus	days per week
Carpool	days per week
Vanpool	days per week
Bicycle	days per week
Walk	days per week
Telecommute	days per week
Other	days per week
Describe:

2) How many miles is it from your home to work? miles 3) How many days a week do you normally drive alone to work? days 4) What are your normal work schedule hours? (example 8am - 5pm) 5) Please check if you work: Flexible Hours , Saturdays , Sundays 6) Which of the following situations prevent you from using an alternative mode of transportation more often when you commute to work? (Check all that apply)
If a family member or I got sick, and I had to leave work early.
If a family member or I had an emergency, and I had to leave work.
If I am asked by my supervisor to work late and I missed my ride.
If my carpool driver had to leave early or stay late.

7) Please add any other reasons that prevent you from using an alternative mode of transportation more often for your daily work commute:

8) Will you use an alternative mode of transportation more often when you commute to work because of the RideSurance program?		Yes OR No

9) In the past year, have you registered with the 511.org ridematch service to find a carpool partner or bike buddy?	Yes OR No

10) Is your employer a member of Ecology Action’s Transportation Services?	Yes No Unsure

11) How did you hear about the RideSurance program?


12) I am interested in receiving additional information about alternative transportation options and incentive programs.	Yes OR No

Please read the following carefully:

Participant Agreement:

I understand the guidelines of the RideSurance 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.

I hereby release the Santa Cruz County Regional Transportation Commission, Ecology Action, and the Pajaro Valley Transportation Management Association from any liability, claims, and demands for personal injury, loss, theft, or damage to my personal property, loss of income, consequential damages resulting from delays or absence of a taxi, or termination of the program.

Program Contact

Piet Canin

Program Director, Transportation Group
Phone: 831-426-5925 x127
Fax: 831-423-3895
Email