Occidental College U-Pass Student Information Form

The information below is requested as part of Metro’s Title VI reporting requirement to the Federal Transit Administration (FTA). The FTA requires that all direct recipients of Federal funding document their compliance with the Department of Transportation’s Title VI regulations. Title VI consists of numerous requirements, including Fare Equity Analysis for Fare Changes. Metro must secure demographic data for all participants of the U-Pass Pilot Program and report aggregated data back to the Metro Board of Directors within the first 6 months. No individual data will be shared. Thank you for your assistance with this matter and for ensuring that Metro meets all federal requirements. If you have any questions regarding the Title VI Reporting requirements, please feel free to contact the Office of Civil Rights at (213) 922-2403.

1. Student ID#:*

2. Name*

First Name

Last Name

3. Email*

4. Zip Code*

5. How many miles do you live from school?*

6. If you currently ride Metro, what type of fare do you use?*

College/Vocational pass Regular 30-day monthly EZ Pass Pay as you go (cash/TAP) I don't ride Metro

7. "Pay as you go" - How many times a week do you ride Metro?*

2 4 6 8 10 12 14 or more

8. If you have a TAP card, please provide the 16-digit card number (located on the back of the card) or enter N/A (non-applicable):

9. Units currently enrolled in:*

0 - 5 units 6 units 7 units 8 units 9 units 10 units 11 units 12 units or more

10. Expected graduation date: Quarter/Semester*

10.a Expected graduation date: Year*

11. Current employment status:*

Full-time Part-time Not employed

12. Age:*

17-21 22-25 26-30 Over 30

13. Ethnicity:*

Asian Or Pacific Islander Black Hispanic Native American White Two or more

14. Annual household income:*

Under $15,000 $15,000-$24,999 $25,000-$34,999 $35,000-$49,999 $50,000-$99,999 $100,000-$149,999 $150,000-$199,999 $200,000 and over

Metro is considering launching a new service called Metro Ride. Metro Ride is an on-demand ride-sharing service in a car or shuttle driven by a Metro employee that provides safe shared short rides, anywhere within the designated service area. You would be able to book and pay for your ride with a mobile app or by phone. Once booked, you would walk to a nearby pick-up point to meet the driver. You may ride with between one to six people along the way to your destination. The service will be more affordable than Uber or Lyft and if desired, you would be able to transfer for free to Metro rail or bus.

16. How appealing is Metro Ride to you?

Very appealing Somewhat appealing Neither appealing or unappealing Somewhat unappealing Very unappealing

17. Would you consider using Metro Ride?

Definitely would consider Probably would consider Might or might not consider Probably would not consider Definitely would not consider

19. If you were going to use Metro Ride, what type of transportation would Metro Ride be most likely to replace? (Choose one.)*

Driving alone Driving with Others Shared Lyft/Uber (Lyft Line or Uber Pool) Non-shared Lyft/Uber Bicycling / Scootering Train Bus Walking

20. I agree (opt in) to receive future communications from Metro, including information on program changes, destinations and discounts.*

Yes No

I understand that my school is participating in the Metro Universal Pass Program (U-Pass) with the Los Angeles County Metropolitan Transportation Authority (LACMTA/Metro). I understand as a part of the Metro U-Pass, I will be issued a TAP Card/Sticker. I understand that my TAP Card/Sticker is nontransferable and cannot be used to cover boardings for any other person, including family members or friends.

I consent to my school assembling on behalf of Metro and providing to Metro, information Metro requires in order to implement the billing, account settlement, enforcement, or other financial activities of the Metro U-Pass program. Such information includes but is not limited to my name, Metro U-Pass ID number, school ID number, and my completed and signed Online Application or K-12 Student TAP Card Application and Just Transit Pilot Program Supplemental Application.

I will use the TAP Card/Sticker in accordance with the terms of the TAP Cardholder Agreement (available at www.taptogo.net or by contacting 1-866-TAPTOGO) and the Metro Customer Code of Conduct (available at http://media.metro.net/about_us/ethics/images/codes_ethics_customers_2014-07.pdf) for its intended purpose only and not to damage, abuse or allow any other unauthorized individual to use it. Metro and/or any Los Angeles County law enforcement agency retains the right to confiscate a TAP Card/Sticker or pursue claims, demands, or lawsuits against, or seek prosecution of, any person who duplicates, alters, or commits unauthorized use of a TAP Card/Sticker. No credit or refund will be issued for proration of unused balances to participant should Metro or any Los Angeles County law enforcement agency confiscate TAP Card/Sticker, pursuant to this section. Misuse of a TAP Card/Sticker will result in deactivation of the TAP Card/Sticker by Metro. Metro may refer any information regarding such events to authorities for prosecution.

21. By clicking "Agree" I am agreeing with the statement above:*

Agree Disagree

22. Signature*

[clear]

Use your mouse or finger to draw your signature above

Occidental College U-Pass Student Information (Disclaimer/Waiver) Form