Name:
*
First Name
Last Name
Email:
*
Address:
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone:
*
(###)
###
####
Employer:
*
Gender:
*
Male
Female
Non-binary
Date of Birth:
*
MM
DD
YYYY
Race/Ethnicity:
*
African American, African, Afro-Caribbean or Black
Native American or Alaskan Native
Asian American or East Asian
Latinx/Hispanic or Chicanx
Native Hawaiian or Pacific Islander
Caucasian/White
Multi-Racial
N/A
Annual Household Income:
*
Total number of people in the household:
*
1
2
3
4
5
6
7
8
9
10 or more
Number of children under the age of 18:
*
0
1
2
3
4
5
6 or more
Current employment situation:
*
Employed
Unemployed
Under-employed
JobRide will help me:
*
Please make between 1 & 2 selections from the choices below.
Do you have a transportation alternative available?
*
Yes
No
If yes, what?
Employer Street Address:
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Is this a temp agency?
*
Yes
No
If your work location is different than your employer's address, enter drop-off location here.
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Is your work schedule fixed or variable?
*
Fixed
Variable
If schedule is variable, please give us the details here.
If your work schedule is fixed, complete shift start and end times like this example : 4:30 am - 12:00 pm.
Sunday shift start time:
Sunday shift end time:
Monday shift start time:
Monday shift end time:
Tuesday shift start time:
Tuesday shift end time:
Wednesday shift start time:
Wednesday shift end time:
Thursday shift start time:
Thursday shift end time:
Friday shift start time:
Friday shift start time:
Saturday shift start time:
Saturday shift end time:
Do you have a disability that requires alternate accommodations?
*
Yes
No
If other, please explain here:
Are you eligible for ParaTransit?
*
Yes
No
How did you hear about JobRide:
*
Please make between 1 and 9 selections from the choices.
If referred by a current JobRide user, please provide their full name for a referral discount:
Comments, questions, or suggestions:
Thank you for completing the YW Transit Job Ride application. Completion of this application does NOT guarantee transportation.
Please note that our service is in high demand with very limited availability.
We will review your application as quickly as possible. If we have an opening in our routes that will work with your requested times and locations, we will be in contact with you to set up your transportation.
If you do not receive a response from us, unfortunately we are unable to accommodate your ride request at this time but will keep your application on file and reach out to you if an opening becomes available.
If your address, employer or phone number should change, please feel welcome to submit a new application.
We appreciate your interest in our program.
Jamie Adams
