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Ridematch Application



Rideshare Registration:

Register in the confidential, online database to receive ridematches for carpooling and vanpooling in our service area and to enroll for Emergency Ride Home reimbursements. If you wish only to enroll in the Emergency Ride Home, check the box in the square below. If you sign up for ridematching, you automatically are enrolled in the Emergency Ride Home program. Provide complete information, as this helps us better serve you. You can change your information if your circumstances, such as hours of work or work location, change in the future.



I would like to receive carpool and vanpool matches and be enrolled in the Emergency Ride Home Program

I do not wish to be matched, but am eligible for the Emergency Ride Home Program; I use one of the commute options listed below (other than driving alone) at least two (2) days per week.

** Please note that if you have previously signed up to receive carpool or vanpool matches you are automatically enrolled for the ERH program

Fields marked (*) are required


Applicant Information:

* Last Name: * First Name:

Middle Initial:

* Home Street Address: Apt #:

Bldg #:

* City: * State: * Zip Code:

* Home Phone: * Alternate Phone:

Sex (M/F):

* Email Address:

Nearest intersection to your home:
and


Company Information:

* Company Name:

* Company Street Address:

Suite #:

* City: * State: * Zip Code:

Department: Mailstop:

Main Phone:

Direct Phone or Extension:

Nearest intersection to your work place:
and


Work Hours:

* Start Time: AM PM

* End Time: AM PM


Days that you work: (check all that apply)

Mon Tues Wed Thurs Fri Sat Sun

Can you arrive and/or leave work within 15, 30 or 45 minutes of your scheduled time?
Yes No

If you answered YES to the above question, check one of the following:
15 30 45


Commuting Information:

Mark the NUMBER of days per week you use each of the following methods of transportation to get to work:


Drive Alone

Carpool/with how many other people?

Vanpool/with how many other people?

Bus

Train

Walk

Bike

Telework


How long have you used your current method of commuting?
Years Months


Additional Information:

Please tell us how you heard about Commuter Services? For example, from your employer, a friend, a billboard or some other way.



In order to protect us from spam, we ask you to please enter the phrase in the shaded area below, exactly as you see it (numbers and letters in upper or lower case) as the security code. This will complete your registration.




Enter the letters and numbers exactly as they appear in the shaded area in the box above.

Agreement

I agree that my information will be entered into Commuter Services' Commuter Database and used for enrollment in their Emergency Ride Home (ERH) program, and that my information will not be provided by Commuter Services to outside marketing agencies. I acknowledge that participation in a carpool or vanpool or the use of other commuting options is an individual decision and that I am responsible for my operation or participation in a carpool or vanpool. Susquehanna Regional Transportation Partnership (SRTP), its contractors, or Commuter Services shall have no responsibility or liability for any claims, expenses or damages resulting from any individual's participation in a carpool or vanpool or use of other commuting options. I acknowledge that it is my responsibility for determining, from any commuter or vendor names provided, the suitability of others to be in a carpool/vanpool/ERH ride with me, including but not limited to background, driving history, and roadworthiness of vehicles. I may choose to be removed from the Commuter Services Commuter Database at any time upon my request. I understand I must be at least 18 years old to participate in this program.

Commuter Services is a program of the non-profit Susquehanna Regional Transportation Partnership, whose board includes the Harrisburg Regional Chamber; the Gettysburg Adams, Lebanon Valley, Greater Chambersburg, and York County Chambers of Commerce; Lancaster and Greater Reading Chambers of Commerce & Industry; Adams County Transit Authority (ACTA); Berks Area Regional Transportation Authority (BARTA), County of Lebanon Transit Authority (LT); Red Rose Transit Authority (RRTA, Lancaster); York County Transportation Authority (rabbittransit); Capital Area Transit (CAT, Cumberland-Dauphin-Harrisburg); Lancaster, Lebanon, Reading Area and York metropolitan planning organizations (MPOs); Harrisburg MPO (Cumberland, Dauphin and Perry counties) and Adams and Franklin counties Rural Planning Organizations (RPOs). One board seat is also set aside for a corporate executive. Funding is provided by the Federal Highway Administration and PennDOT in partnership with the participating MPOs and RPOs.

Commuter Services • 2951 Whiteford Rd. Suite 201 • York, PA 17402