Name* First Last Home Address* Street Address City ZIP Code Home Phone*Email* Employer Name* Work Address* Street Address City ZIP Code Work Phone*To qualify for the 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 ERH participants. All information will remain anonymous.Baseline Survey I plan to use the following travel methods to get to work in the upcoming year (put estimated number of days per week): 012345+Drive AloneDrive Alone BusBus CarpoolCarpool VanpoolVanpool BicycleBicycle WalkWalk TelecommuteTelecommute OtherOther DescribeHow many miles is it from your home 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 No Unsure Is your employer a member of Ecology Action’s Transportation Services? Yes No Unsure Terms and Conditions: I understand the guidelines of the Emergency Ride Home Program. I am eligible to use this program by traveling to work at least one day per week using an alternative mode of transportation. I understand that I can be reimbursed for up to two rides per calendar year, and that the rides are to be used during work hours, and only on days when I have used an alternative mode of transportation for my commute. By clicking the "Submit" 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/ride hail, or termination of the program. Emergency Ride Home Procedures: On preregistering with Ecology Action, the employee will receive a reimbursement form. The reimbursement form must be signed by employee and the employee transportation coordinator, supervisor, or administrative staff associated with this program. For each year that an employee elects to use alternative transportation, two reimbursements can be dispensed. In an emergency, the employee can hail an Uber/Lyft, call a taxi, ride the bus, rent a JUMP bike, or rent a car if applicable (each employee who uses this program is responsible for following the proper internal company procedures which apply to leaving the workplace during a work shift.) On reaching their destination, the employee needs to save a valid ride receipt from the transportation option selection. Once a valid receipt accompanying a completed and signed reimbursement form is submitted, Ecology Action will reimburse employee for the full cost of the ride. Ecology Action or the member employer has the right to verify the trip purpose of any ride taken under this program. Abuse of the program may result in disciplinary action and/or expulsion from this program or other programs offered by Ecology Action. Exclusions: This program is not designed for your personal use for errands, pre-planned medical appointments, business-related travel, or working late without a supervisor’s request. Transportation to a doctor or hospital resulting from an on-the-job injury is not covered by this program. Your company has separate procedures for worker’s compensation incidents. In the event of a major area disaster, this service is not available. It is wise to make advance transportation arrangements to apply in the case of a major area disaster. For more details and information, contact Ecology Action, your Employee Transportation Coordinator, or your supervisor. Any person who is diagnosed or exposed to COVID-19 may not use this service. Acknowledgement* I have read and agree to these Terms and Conditions NameThis field is for validation purposes and should be left unchanged.