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LAST Name:
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FIRST Name: |
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Home
Address: |
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City:
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State
and
Zip Code: |
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Employer: |
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Department: |
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Supervisor: |
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Work
Address
(include mail zone if applicable): |
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Work
City, State, Zip |
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Work Phone:
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Email
Address: |
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Arrival Time |
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Departure Time |
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Estimated Mileage ONE WAY: |
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Please
send me a replacement voucher. |
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In most cases, where would you need to get to in
case of an emergency:
(PLEASE SELECT ONLY ONE
OPTION) |
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Home (I do not
park my vehicle at a transit station or other)
Transit Station (I park my vehicle here and would
need to get to it). Please specify:
Other. Please provide details here:
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Please enter the number of days per week you currently travel by: |
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Terms of Agreement for
Guaranteed Home Program
Please put your initials in each text box to the left below.
You will
not be able to participate if you do not read and
initial each line. |
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I
request to participate in the Seaport TMA's
Guaranteed Ride Home
Program. I have read, printed out and agree to
the terms outlined in the
document titled ASSUMPTION OF RISK, WAIVER OF
CLAIMS AND INDEMNITY AGREEMENT. |
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I
hereby release Seaport TMA from any liability, claims and demands for
personal injury, loss, theft or damages to my personal
property, loss of income, consequential damages
resulting from delays or absence of service provider,
or termination of the program. I also understand that
Seaport TMA has the right to discontinue
participant privileges at any time. |
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I
understand that the Seaport TMA requires me to
complete a follow-up confirmation report if I
use the Guaranteed Ride Home to ensure that my travel
needs were met. I understand that the report must be
completed and submitted within one week after each use
of the program to be eligible for another Guaranteed
Ride Home voucher. |
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Furthermore, I understand that incorrect use of this
service may result in revocation of reimbursements and
restriction from using the service again. |
