CommuteWorks - Emergency Ride Home Program - Services and Information provided by CommuteWorks

Registration Form
Items marked by an asterisk (*) are required

Contact Information
Date*:	(e.g. 01/01/99)
Name*:
Home Address*:
City*:
State*:
Zip*:
Home Phone*:
How far (in miles) is your home from the LMA each way?*

Work Information
Employer*:
Phone*:
Department:
Time Work Begins*:
Time Work Ends*:
Job Type:

Ridesharing Information
What program are you currently enrolled in?	Carpool Vanpool T-Pass Subsidy CommuteFit

If in a Vanpool:
What is the town of origin?
What is the name of the primary driver?

If in a carpool please list carpool partners:
1. Name:
2. Name:
3. Name:
4. Name:
Parking Information: List where you usually park in the LMA. If you park in more than one location, list all locations.
#1:
#2:
#3:
If in the CommuteFit Program: How many days a week do you walk, run, rollerblade or bike to work?

Emergency Information
In the event that the emergency is concerning yourself or a family member, is there someone else you would like us to contact ?
Name*:
Relationship*:
Phone Number*:
Request to Participate in the Emergency Ride Home's Release of Liability I, the undersigned, request to participate in CommuteWorks' Emergency Ride Home Program. I have read and agree to abide by the policies, rules, and regulations of the Emergency Ride Home Program. I understand that transportation to my home will be provided to me by third party vendors, who are retained by CommuteWorks. I understand that CommuteWorks is not responsible for the performance of the vendor providing transportation to me. In consideration of my request to participate in the Emergency Ride Home Program, I hereby assume full responsibility for all risk of injury or loss, including death, which may result from my participation in the program. I hereby agree to hold harmless, release, waive, forever discharge and covenant not to sue or bring claim against CommuteWorks, MASCO, their officers, agents, or employees from any and all claims and demands whatsoever which the undersigned or any third party, and the representatives thereof may have against the said company, officers, agents, or employees, by reason of any accident, illness, injury, or death or damage to or loss or destruction arising or resulting directly or indirectly from my participation in the Emergency Ride Home Program and occurring during said participation, or anytime subsequent there to, whether or not such loss, injury or death is caused in whole or in part by the negligent acts or omissions of the company, their officers, agents, or employees. The terms of this release shall serve as a release and assumption of risk for my heirs, executors, administrators, and for all of my family members. I, the undersigned, agree to abide by the policies, rules, and regulations of this program. In the event, that I utilize the program in an unauthorized manner, resulting in the expense of CommuteWorks/MASCO, I agree to promptly reimburse CommuteWorks/MASCO for all damages resulting from the unauthorized utilization of the program. CommuteWorks' Emergency Ride Home Program will operate while supplies last. Thank you for registering with the CommuteWorks' Emergency Ride Home program. By submitting this form, you agree to the terms & conditions stated above. Please hit Submit now to send your info.