PUSD Harvest Park Middle

Student Transit Pass Application

Alameda County Student Transit Pass Program

PUSD Harvest Park Middle

Application Instructions

To enroll in the Student Transit Pass program, complete the below application. All fields marked with an asterisk (*) are required.

Eligible students get a FREE Youth Clipper card that provides unlimited free rides on Wheels. Students can add cash value to the Clipper card for 50% off BART fares and youth discounts on other transit systems that use Clipper.

For more information about program eligibility visit: https://www.alamedactc.org/programs-projects/studentpass/

Review Clipper Cardholder License Agreement and Metropolitan Transportation Commission Privacy Policy at:

https://www.clippercard.com/ClipperWeb/agreement.do/

https://www.clippercard.com/ClipperWeb/privacy.do/

District

School

School Name*

Harvest Park Middle Other

You are using the incorrect application, please do NOT submit this form. Please use the link below to find the correct application for your school.
Link: Student Transit Pass Program - Alameda CTC.

Student Contact Information

Have you received a Student Transit Pass Clipper card this year or in past years?*

Yes No

If yes, YOU DO NOT NEED to submit a new application, your card is VALID UNTIL YOU GRADUATE from high school. However, if your card has been lost or stolen, you can request a replacement card using this form.

Do you currently have a Student Transit Pass Clipper card that you HAVEN'T used in the last 6 months?*

Yes No

If you haven't used your card in 6 months, it might have become inactive. YOU DO NOT NEED to fill out this application. Please EMAIL STPP@LAVTA.ORG with your Clipper Card Number to request reactivation for your card. For any further questions, you may call 925.455.7500.

Student Name*

First Name

Middle Name (optional)

Last Name

Suffix (optional)

Student Date of Birth*

This information must match school records

Home Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Home Phone

Student Grade Level*

Student ID Number*

This information must match school records

Student Email Address

Confirm Student Email Address *

Does the student have an existing Youth Clipper card?*

Yes, please add the STPP pass to the student's existing card No, the student is new to the STPP program and needs a card No, the student enrolled in the STPP program previously and needs a replacement card

Please provide the 10-digit card number associated with your existing Youth Clipper card.*

Parent or Guardian Signature

By signing, I (parent/guardian) attest that the information on this application is correct.

Parent or Guardian Signature*

[clear]

Use your mouse or finger to draw your signature above

Date*

Alameda CTC Income Verification Requirement

To be eligible for the Student Transit Pass Program (STPP), a student must be a full-time middle or high school student and the student’s family income must be at or below the levels indicated below.

Please select which category you qualify for in the table below. By signing on the first page of this application, you certify that your household’s gross annual income is at or below the annual income limit indicated for your household size.*

Household Size: 1 / Annual Income Limit: $25,142 Household Size: 2 / Annual Income Limit: $33,874 Household Size: 3 / Annual Income Limit: $42,606 Household Size: 4 / Annual Income Limit: $51,338 Household Size: 5 / Annual Income Limit: $60,070 Household Size: 6 / Annual Income Limit: $68,802 Household Size: 7 / Annual Income Limit: $77,534 Household Size: 8 / Annual Income Limit: $86,266

*By submitting and signing this application, the minor participant’s parent/legal guardian (“Applicant”) is providing written consent to the following terms and conditions for participation in the Student Transit Pass Program. Applicant agrees to the terms and conditions of the Clipper Cardholder License Agreement and Clipper Privacy Policy. Visit clippercard.com or call Clipper Customer Service at 877.878.8883 (TDD 711 or 800.735.2929) to obtain a copy. Applicant authorizes Alameda CTC and AC Transit to retain and use the personally identifiable information provided in this Student Transit Pass Program Application only for the purpose of communication and data management related to this program. Participant’s card usage history data maintained by AC Transit and Alameda CTC or the Clipper Program will only be used at the aggregate level for the purpose of program evaluation and administration.