Guaranteed Ride Home Registration Form

Personal Information

Name: (required)

Home Address:

City: State: Zip:

Home Phone: (required)

Your Email: (required)

Work Information

Employer: (required)

Supervisor:

Begin work at (specify AM or PM):

Leave work at (specify AM or PM):

Work Address: (required)

City: (required) State: Zip:

Work phone: (required)

Please include any mail codes used at your work site!
Taxi vouchers and program materials are sent via US Mail to your work address only.

Commuting Information

My primary method of commuting to work is (check as many as apply):
 Bicycle Bus Carpool Commuter Train Shuttle Subway Vanpool Walk

If other, please describe:

Please identify train, subway or bus route(s):

Please identify fellow carpoolers/vanpoolers by name and phone number:

Driver:

Driver number:

Rider:

Rider number:

Terms and Conditions for Employee Participation and Release of Liability
By submitting this form, I request to participate in the Merrimack Valley Transportation Management Association's (MVTMA) Guaranteed Ride Home Program ("Program"). I have read and understand the policies, procedures, rules and regulation of the Program, and I agree to abide by them.

I understand that under the rules of the Program, transportation will be provided to me by a third party vendor, who is retained by the Merrimack Valley Transportation Management Association. I also understand that the MVTMA, Northeast Transit Planning & Management Corp, MVTMA member organizations and my employer are not responsible for the performance of the transportation vendor.

I hereby agree and state that I am an eligible employee of a member organization of the Merrimack Valley Transportation Management Association. I agree that if I use the Program in an unauthorized manner, I will promptly reimburse MVTMA for all damages resulting from the unauthorized use of the Program. I further agree to use my best judgment in participation in the Program and to faithfully adhere to all safety instructions and recommendations, whether oral or written. I hereby certify that I am a competent adult assuming these risks of my own free will, being under no compulsion or duress. I understand that my abuse of the Program may result in the loss of my eligibility to use its services in the future.

I, by requesting to participate in the Program, hereby assume full responsibility for all risk of injury or loss, including death, which may result from my participation in this Program and hereby agree to hold harmless, release, waive, forever discharge and covenant not to sue or bring claim against MVTMA, Northeast Transit Planning & Management Corp., MVTMA officers, agents, members and/or employees, and my employer, from any and all claims and demands whatsoever which the undersigned or any third person, and the representatives thereof have or 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 of any property arising or resulting directly or indirectly from my participation in the Program and occurring during said participation, or any time subsequent there to, whether or not such loss, injury or death is caused or alleged to be 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 risks for my heirs, executors, administrators and for all of my family members.


 By checking this box you certify that you have read and agree to the "Terms and Conditions for Employee Participation and Release of Liability" statement above. (required)

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