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Emergency Ride Home Registration Form

for Transit Riders, Bicyclists and Walkers working in the UV.

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

Work Email:    

Department:    

Number of days/wk using alt. commute: 	

Interest in carpool information (Y or N): 

Interest in brochures/posters for employer site (Y or N):      

Alternate Commute mode? Transit Walk Bicycle Other
Name of Transit system (Required):  

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 via transit, bike or walking, to an employer site located in the Advance Transit service area (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 the employees of Advance Transit, Inc. 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, Advance Transit, Inc. and the Emergency Ride Home Program. (9/18/08)

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Main Menu | Carpool Reg. | Carpool List | Park & Ride Lots | Guar. Ride Home | Emerg. Ride Home | Fun Facts

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