Sonoma County Safe Routes to Schools Enrollment Form
1. School Name *
Your answer
2. School District *
Your answer
3. School Principal *
Your answer
4. Principal Phone *
Your answer
5. Principal Email *
Your answer
6. Fax
Your answer
7. Applicant Name (if different than principal)
Your answer
8. Applicant Title/Position
Your answer
9. Applicant Phone
Your answer
10. Applicant Email
Your answer
11. School Enrollment *
Your answer
12. Number of 4th grade classrooms (if applicable) *
Your answer
13. Has your school ever participated in the Sonoma County Safe Routes to School program, or held walking or bicycling events? *
14. What are your goals for participating in the Sonoma County SRTS program for the 2017-18 school year? *
Your answer
Questions 15-18 ask you to select the Education, Encouragement, and Engineering program activities you are interested in implementing. Note: Some activities are only available on a limited basis and/or require you to register in advance. Enrolled sites will be notified when registration opens for those activities.
15. What elements of the SRTS Encouragement Program would you like to receive support for implementing in 2017-18? Check all that apply. At least one must be checked. *
Required
16. What elements of the SRTS Education program would you like to implement in 2017-18? Check all that apply.
17. Are there topographic/geographic or other barriers that affect travel to school (such as: located on a steep hill, along a major arterial, a rural windy road with no sidewalks, over 60% of students ride the bus or live more than 1 mile from school, etc?). If so please describe.
Your answer
18. What elements of the SRTS engineering program would you like to implement?
19. % of students living within 1 mile of school (please make your best guesstimate) *
Your answer
20. Does your school have an existing or potential SRTS Champion (a designated school site coordinator who could assist in implementing the program, either parent volunteer or school staff?) *
21. If yes to question #20, please fill in:
a. Name of champion
Your answer
b. Phone
Your answer
c. Email
Your answer
22. Does your school have an existing SRTS, safety, transportation, or wellness committee? *
23. If yes, name of committee:
Your answer
24. What school safety/active/alternative transportation policies are already in place at your school? *
Required
25. Sonoma County SRTS staff provides some assistance to organize encouragement activities. How much assistance do you anticipate needing from Sonoma County SRTS staff to organize an encouragement activity or event, such as a Walk and Roll to School Day event? *
26. I understand that implementation of education activities listed above requires a school point person for scheduling, coordination, and, in some cases, promotion. *
Required
27. I understand that my school will be asked to conduct in-class student travel-mode tallies in the Fall and Spring if receiving one or more of the following free services: 4th grade bicycle rodeo, after-school bicycle rodeo, family bicycle workshop, 6th or 7th grade “Drive Your Bike” lessons, free incentive items or technical support for more than 1 walk/roll event per year (an online form will be provided to share with teachers in order for them to conduct tallies. Assistance in conducting tallies may be available if requested). *
Required
28. If someone other than the Principal filled out this form, please confirm:
29. If you would like to make additional comments or ask a question, please do so here:
Your answer
Programming Safe Routes to School Activities at each school will be based on assessment of school needs, prior services, and location, and the available Sonoma County Safe Routes to School budget.
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