Survey - JobRide Application

JobRide Application

The service is full at this time. Please complete this application to be added to our waitlist. Completion of this application does NOT guarantee transportation. If you currently reside within a bus line and have access during service hours, we cannot accept your application for transportation. Our routes are pre-scheduled. Work days/times must be entered in order for your application to be considered. All information you provide is for eligibility and reporting purposes only.

Contact Information

Name:

First Required	Last Required

Email: Required

Street Address: Required

Apt/Box/Unit/Suite:

City/State/ZIP:

City Required	State Required	ZIP Required

Phone Number: Required

Employer: Required

Gender: Required

Date of Birth: Required

Date of Birth:

Yes, I would like to receive update e-mails from YWCA Madison.

Yes, I would like to receive postal mail from YWCA Madison

Question - Required - Annual Household Income

(Maximum response 255 chars, approx. 5 rows of text)

Question - Required - Number of children under the age of 18

Question - Required - Total number of people in the household

Question - Required - Current employment situation

Question - Required - JobRide will help me
Please make between 1 and 2 selections from the choices below.

	Get a job
	Keep a job
	Get a better job

Question - Required - Do you have a transportation alternative available?

Question - Not Required - If yes, what?

Question - Required - Employer Street Address

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Employer City

Question - Required - Is this a temp agency?

Question - Not Required - If your work location is different than your employer's address, enter drop-off location here.

(Maximum response 255 chars, approx. 5 rows of text)

Work Schedule:

Our routes are pre-scheduled. Work days/times must be entered in order for your application to be considered.

Question - Required - Is your work schedule fixed or variable?

Question - Not Required - If schedule is variable, please give us the details here.

(Maximum response 255 chars, approx. 5 rows of text)

If your work schedule is fixed, complete shift start and end times like this example: 4:30 am - 12:00 pm.

Question - Required - Sunday shift start time

Question - Required - Sunday shift end time

Question - Required - Monday shift start time

Question - Required - Monday shift end time

Question - Required - Tuesday shift start time

Question - Required - Tuesday shift end time

Question - Required - Wednesday shift start time

Question - Required - Wednesday shift end time

Question - Required - Thursday shift start time

Question - Required - Thursday shift end time

Question - Required - Friday shift start time

Question - Required - Friday shift end time

Question - Required - Saturday shift start time

Question - Required - Saturday shift end time

Demographics:

These responses are required for FoodShare Employment and Training program tracking. All information is kept strictly confidential.

Question - Required - Do you have a disability that requires alternate accommodations?

Check if you use any of the following

(Select one of the available choices or enter a different value.)
Question - Not Required -

Question - Required - Are you eligible for ParaTransit?

Question - Required - How did you hear about JobRide
Please make between 1 and 9 selections from the choices below.

	From a current JobRide user
	From a friend
	From a brochure
	From an advertisement
	From an employer
	From a search engine (for example Google)
	From the YWCA website
	From another website
	From another source

Question - Not Required - If referred by a current JobRide user, please provide their full name for a referral discount.

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Comments, questions, or suggestions

Question - Required - To help us reduce spam, please complete this CAPTCHA

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