Getthere Transportation to Employment Referral Form

Getthere Transportation to Employment Program Referral Form
Getthere's Transportation to Employment Program (TEP) helps to remove transportation as a barrier to employment for Broome, Chenango, Cortland, Delaware, Otsego, and Tioga County residents.
- TEP provides short-term transportation assistance in the form of bus passes, taxi rides, a network of volunteer drivers, and fuel cards - to be used for a personal vehicle or a carpool.
- We work with each person to develop a sustainable transportation strategy that allows them to pay for their own transportation long-term in order to maintain their job and move towards financial stability.
Program participants may be asked to provide proof of employment, which can include a new hire letter/email, supervisor name and phone number, or paystub.
Referring Agency or Business Information
Agency or Business Name:*
Contact Person*

First NameLast Name
Phone Number
Please enter a valid phone number.
Email Address*
example@example.com
Referral Information (Person Seeking Transportation Assistance)
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Phone Number*
Please enter a valid phone number.
Email Address
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County:*

BroomeChenangoCortlandDelawareOtsegoTioga
Gender

MaleFemaleNon-binary
Race/Ethnicity

American Indian/Alaska NativeAsianBlackHawaiian/ Pacific IslanderWhiteUnknownOther
Medical Insurance
CIN# if Medicaid
*** Medical insurance or lack thereof does not disqualify individuals from assistance.
Barriers to Employment (Check ALL that Apply):*

TransportationAccess to foodAccess to health careAffordable housingChild careEducational attainmentFormerly incarceratedPhysical/mental healthSocioeconomic StatusSubstance UseTraumaUnemployment/underemploymentOther
Authorization to Release Personal and Health Information to a Third Party

By submitting this form, the referred individual understands that I am allowing the Rural Health Network to use or disclose their personal and health information. This information may be shared for program services and/or program evaluation. Personal and health information will not be released to the public.

1. Purpose of use/disclosure: Getthere Transportation to Employment Program

2. The referred individual understands that, with few exceptions, they may see/copy the information described in this form and they may get a copy of the form after it is submitted if they request it.

3. The referred individual may revoke this authorization at any time by notifying Getthere in writing at the address below. If they do, it will not have any effect on the actions that Getthere took before receiving the revocation. If not previously revoked, this authorization will expire upon completion of this request or one year from the date this form is signed, whichever comes first.

4. The referred individual understands that this authorization is voluntary. The individual understands that if the organization authorized to receive the information is not a human service, public workforce, or public service agency, the released information may no longer be protected by federal privacy regulations and therefore the recipient of the confidential data may re-disclose the confidential data.
The referred individual seeking transportation assistance consents to sharing personal and health information as listed above.*

Yes
Rural Health Network of South Central New York

Getthere Mobility Management Program

455 Court Street

Binghamton, NY 13904

(607) 692-7669 - Rural Health Network

(855) 373-4040 - Getthere
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Getthere Transportation to Employment Program Referral Form