Name (first & last):
Home Address 1:
Home Address 2:
email address (if you have one):
Nearest major cross street:
Round trip miles to work:
Please check if you work:
What is your normal work schedule?
from AM PM
If you work another shift, tell us the hours:
Do you need riders?
Please refer to the
Emergency Ride Home Policies & Procedures
to find out if you are eligible for a cab or a rental car.
Employer Address 2
Is your rideshare a:
Express Bus Route (enter route number)
Choosing the Express Bus Route option will disable fellow riders fields below. Proceed to the "Additional comments/questions" area.
I hearby attest that I share a ride to my worksite at least three (3) days a week or
fifteen (15) days each month with the person or persons named above. I further attest that I have read the policies and
procedures of the Emergency Ride Home service and agree to comply with those policies and procedures. I hearby release the
Regional Transportation Authority, its officers, board of directors, agents and employees from all liability, claims, suits,
demands or damages for personal injury, loss, theft or damage to my personal property; loss of income; or consequential
damages resulting from delays or absence of cab or rental car; or termination of the program.
By checking this box, you confirm the above statement.