SafeRides 2024-2025 Registration Form

SafeRides of Ridgefield Team Member Application

Fall 2024 - Spring 2025 General Membership
Calling all Juniors and Seniors! The Safe Rides program is back!

Thank you for your interest in joining the Safe Rides of Ridgefield program. Please complete the following application by Friday Nov. 15, 2024 to be a part of the Safe Rides team. Please note that all sections of the application must be completed in full for your registration to be marked as "complete". A parent/guardian will need to be with you to complete this application and sign up for a minimum of one night of adult supervision of the Safe Rides program.

Before you can complete your application, you will be directed to a PayPal payment form where you can submit payment for your non-refundable registration fee of $35.00. You will need an active PayPal account to submit payment. Please share this application with friends, peers, teammates, club members, etc. It is open to all current high school juniors and seniors. For more information on the Safe Rides program, go to www.saferidesofridgefield.org. Safe Rides will follow town of Ridgefield COVID protocols.

All applications for Fall 2024 -Spring 2025 membership must be completed by EOD on Friday November 15.

SafeRides Student Pledge

SafeRides of Ridgefield is a Family & Community Commitment. This commitment is essential to the safe and continuous role of SafeRides in our town. We work closely with the Ridgefield Police and Fire Departments. In addition to you, the student, we require families to take part in SafeRides by committing to volunteer for at least one night of adult supervision. By checking the following boxes, you agree to the terms of SafeRides membership and responsibilities.
I will know when I am working and be there on the assigned night and time.*

I agree
If I cannot be at SafeRides the night my team is on duty, I will find another member of SafeRides as a replacement and notify my leader.*

I agree
ALL NEW SafeRide applicants are required to attend the mandatory SafeRides training.*

I agree
I understand and acknowledge that I will follow the rules developed by SafeRides of Ridgefield. I will not drink alcohol, use illegal substances, or be impaired in any fashion during the day or night that I am assigned to work at SafeRides.*

I agree
It is my responsibly to have a parent/guardian/adult commit to AT LEAST one night of SafeRides supervision and failure to do may result in my dismissal from the SafeRides program.*

I agree
In order for an application to be considered "complete", we must receive this application and $35 payment by the application deadline of November 15, 2024. A link to SafeRides Adult Supervision sign up will be sent by your Team Captain along with your team assignments.*

I agree

SafeRides + Key Club Acknowledgment

I understand that Safe Rides of Ridgefield operates in partnership with the RHS Key Club. By continuing with and completing this application, I agree to join the RHS Key Club and participate in club activities of my choice for the 2024-2025 academic year.
I agree to participate in RHS Key Club activities for the 2024-2025 academic year*

I agree

Applicant Information

Please fill out all fields below. If a field does not apply, please leave it blank.
Full Name*

First NameLast Name
Email Address*
example@gmail.com
Issue Date of Driver's License

MonthDayYear
*If you do not have a driver's license, please leave this field blank.
Home Phone*

Area CodePhone Number
Cell Phone*

Area CodePhone Number
Applicant's Grade Level for 2024/2025School Year*

JuniorSenior
All NEW applicants are required to attend a SafeRides Training Session. Date to be determined. Training will take place at the Ridgefield Rec Center.*

I agree

Before You Proceed...

The remainder of this application requires a parent/guardian to complete. When your parent/guardian is ready to continue, please click "NEXT" below. By proceeding, you are affirming under oath and penalties of perjury pursuant to Title 28 U.S.C. 1746 and other applicable statutes and laws that you are the parent or guardian of the minor who is enrolling in the SafeRides of Ridgefield Program.
Confirm Below*

I understand and would like to proceed.

Parent/Guardian Information

Please fill out all fields below.
Parent/Guardian Full Name*

First NameLast Name
Parent/Guardian E-Mail Address*
example@example.com
Parent/Guardian Home Phone*

Area CodePhone Number
Parent/Guardian Cell Phone*

Area CodePhone Number
My child has my permission to drive the family or his/her car for Safe Rides duty:*

YesNoNot Applicable
Vehicle Insurance Company*
If your child will not be driving, please enter N/A.
Vehicle Insurance Policy Number*
If your child will not be driving, please enter N/A.
Does your auto insurance policy has liability coverage that meets or exceeds $50,000/$100,000/$50,000?*

YesNoNot Applicable
As a parent/guardian of a student participating in the SafeRides of Ridgefield program, I acknowledge that I am required to serve as an adult volunteer for the program for one shift during the academic year (9:45 pm- 2:00 am). Serving as an adult volunteer will require me to be on site for that entire time period to supervise student activity and act as an escalation point for any situations that may arise. A link to SafeRides Adult Supervision will be sent to your child with their Team Assignment. It is your child's responsibility to share this with you.*

I agree
If for any reason I am unable to attend the night of my assignment, I am responsible for finding a replacement.*

I agree

Insurance Coverage for Volunteers

All vehicles used by volunteers of the SafeRides of Ridgefield program MUST be covered by a liability policy. The amount of this coverage must meet or exceed the insurance requirement of the state in which the vehicle is licensed. (It is recommended however, that coverage limits are at least $50,000/ $100,000/ $50,000.) Any vehicle carrying ten (10) or more passengers is required to have limits of $100,000/$500,000/$100,000 or $5,000,000 single limit. The council’s automobile liability insurance is excess of the insurance the owner of the auto carries, providing insurance protection above the limits carried on the auto up to the council’s limit.
Acknowledgment*

I understand the insurance information above for drivers and would like to continue.

Student Signature
I declare under penalty of perjury under the laws of the United States of America that the information submitted in this form is true and correct.*

I agree
Electronic Signature*

Clear
To sign, simply click anywhere in the white box below and drag your mouse to form your signature. If your device has a touchscreen, you may sign with your finger.

Parent/Guardian Signature
I declare under penalty of perjury under the laws of the United States of America that the information submitted in this form is true and correct.*

I agree
Electronic Signature*

Clear
To sign, simply click anywhere in the white box below and drag your mouse to form your signature. If your device has a touchscreen, you may sign with your finger.

Registration Fee Payment
To assist in covering operational costs of the Safe Rides of Ridgefield program, each applicant is required to pay a $35.00 non-refundable application fee.

Every dollar of this application fee goes towards covering the costs of operating the program throughout the school year.

Click on the PayPal link below to submit your payment. You will need a PayPal account to submit your payment. If you do not have a PayPal account, you may create one for free or, alternatively, you may mail a check payable to Saferides of Ridgefield to Katie Keppler at 71 Ivy Hill Rd. Ridgefield.

In order for an application to be considered complete, we must receive the application and payment by EOD on Friday November 15, 2024. When submitting payment, please enter the student's name into the "Note" field in PayPal or memo area on check.

Attention Juniors!!! If you would like to apply for a position on the Safe Rides Executive Board please complete the Google form here

Please note that your application will NOT be considered complete until both this form and the registration fee payment are recieved.

**** VERY IMPORTANT**** After submitting payment via PayPal, you MUST come back to this form and click "Submit Application" for your app to be considered complete.

Submit Payment via PayPal
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SafeRides of Ridgefield Team Member Application

SafeRides Student Pledge

SafeRides + Key Club Acknowledgment

Applicant Information

Before You Proceed...

Parent/Guardian Information

Insurance Coverage for Volunteers

Student Signature

Parent/Guardian Signature

Registration Fee Payment