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GO ITHACA Registration Form
As a member of GO ITHACA, I pledge to take fewer drive-alone trips or try a new sustainable mode of transportation at least once a week. I pledge to use the following mode(s) of transportation for my commute to work or school and/or to complete errands. (Check all that apply)
Walk
Bike, scoot, skate, or roll
Bus
Carpool
Carshare
Other
Email
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First name
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Last name
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Phone number
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Home Address
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Apt. # if applicable
City
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State
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ZIP Code
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If you're a student, please enter the school name
Cornell University
Ithaca College
Tompkins Cortland Community College
Other
Employee Section
Are you current employed?
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Yes
No
Company Name
Company Address
Company City
Company State
Company ZIP Code
Travel Habits
What time do you typically ARRIVE at work or school? (format: HH:MM AM/PM)
What time do you typically LEAVE work or school? (format: HH:MM AM/PM)
How often do you drive alone in a typical week?
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Frequently
Sometimes
Never
How often do you carpool in a typical week?
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Frequently
Sometimes
Never
How often do you walk in a typical week?
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Frequently
Sometimes
Never
How often do you take the bus in a typical week?
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Frequently
Sometimes
Never
How often do you bike or roll in a typical week?
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Frequently
Sometimes
Never
How often do you use taxis or rideshare (Uber, Lyft) in a typical week?
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Frequently
Sometimes
Never
How often do you telework (work remotely) in a typical week?
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Frequently
Sometimes
Never
If you drive to work or school, where do you park?
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I don't drive to work or school
Seneca Parking Garage
Cayuga Parking Garage
Green Parking Garage
Metered street parking
Private work or school driveway or lot
Wherever I can find a spot that doesn't cost anything (like in the neighborhoods)
Which (if any) of the following does your employer or school routinely provide for you?
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TCAT bus passes
Ithaca Carshare membership
Ithaca Bikeshare membership
Incentives for biking or walking
Monthly garage parking pass
Free parking in company lot
Pre-tax commuter benefits
None of the above
Which of these transportation-related passes do you routinely use?
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TCAT bus pass
Ithaca Carshare membership
Ithaca Bikeshare membership
Backup Ride Home membership
Parking lot or garage pass
None
If you have an existing TCAT pass number, please include it here.
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Demographic Information
Race/Ethnicity (If you are of a multi-racial/ethnic background, please mark all that apply)
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African American / Black
African
Asian
First Peoples of (North / South) America / Alaska Native
Hawaiian Native / Pacific Islander
Hispanic or Latina/o
Middle Eastern / Arab
White / Caucasian
Other
Gender Identity
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Female
Male
Non-Binary
Other
Age
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18-24
25-34
35-44
45-54
55-64
65+
Please indicate whether your household income is at or below 150% of the US Federal Poverty Guideline 150% of the US Federal Poverty Guideline.
Household Size Annual Income
1 $18,735
2 $25,265
3 $29,435
4 $45,255
(see https://aspe.hhs.gov/system/files/aspe-files/107166/2019-pctpovertytool-highlight.pdf if your family has more than 4 members)
If you answer yes, you may qualify for additional discounts and services.
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Yes
No
How did you hear about GO ITHACA? (check all that apply)
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Through the media or press (in a newspaper, news broadcast)
On social media
Through my employer
Through a friend or neighbor
Through my landlord
From an informational table or GO ITHACA event
Other
Additional comments
Do you have any additional comments or suggestions?
GO ITHACA Waiver and Liability Release
I agree to the GO ITHACA Terms and Information Agreement.
Read our terms and conditions here: https://docs.google.com/document/d/1AUIpQ1O7WSgILfJbZ_R9QyBKXHwaHLT_kxqGvUHOOU4/edit?usp=sharing
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