Rideshare - ERH Registration

Name:          
Employer:      
Work Address:  
City:          
State:          Zip: 
Work Phone:    

Work Email:    

Department:    

Supervisor's Name:  

Employer/Parking Location:  

Days you use alternate commute:	      
How do you commute? TransitWalkBicycleOther

Name of Transit System, if you use one:  

Home Mailing Address:  
City:          
State:          Zip: 
Home Phone:    
Home Email (opt):    
I understand that the above information will be used only for client contact and reimbursement purposes, and that from time to time UVRS may send me a mailing or e-mail with new benefit information. I also understand the guidelines of the Emergency Ride Home Program and qualify by commuting on a regular basis by a qualifying alternate commute to an employer site located in the BWC District (Lebanon, Hanover, Hartford, Norwich, Enfield or Canaan). I, on behalf of all my heirs, successors or assign, hereby release and hold harmless my employer, the organizations and their employees involved in the Vermont Rideshare Program, the NH Rideshare Program, Advance Transit and Upper Valley Rideshare from any liability, claims and demands of any kind whatsoever, including, but not limited to, any personal property, loss of income, or consequential damages resulting from transportation provided under Upper Valley Rideshare, Vermont Rideshare, NH Rideshare, Advance Transit and the Emergency Ride Home Program.
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