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Emergency Ride Home Registration Form for Carpoolers and Vanpoolers

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Name:          
Home Address:  
City:          
State:          Zip: 
Home Phone:    
Email:         

Employer:      
Department:    

Work Address:  
City:          
State:          Zip: 
Work Phone:    

Rideshare Method Used:      Carpool Vanpool Other
Carpool Driver's Name:      
Employer/Parking Location:  

I understand the guidelines of the Guaranteed Ride Home Program and qualify by traveling in a Rideshare arrangement: i.e. car/vanpool, shared driving, etc. 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 UPPER VALLEY RIDESHARE Program including Advance Transit, Inc., from any liability, claims and demands of any kind whatsoever, including, but not limited to, any personal property, lose of income, or consequential damages resulting from transportation provided under UVRS, and the Emergency Ride Home Program. (9/18/08)

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