Emergency Ride Home (ERH)

Registration Form

For Office Use Only

To register for the Emergency Ride Home (ERH) Program, you must use a commute option, other than driving alone, at least two (2) days per week and be at least 18 years old.

Bay Area Commuter Services (BACS) reserves the right to refuse or limit participation in this program at any time. The Emergency Ride Home progrom may be discontinued at any time without notice.

 

 

 

In addition to the ERH Program, you may also register to be matched into a carpool and/or vanpool. If you would like to be matched, please check one of the following:

 

 

Carpool Vanpool Both carpool AND vanpool

 

 

To register for the ERH Program ONLY, please check the following:

Emergency Ride Home Program ONLY. I do not wish to be matched.

 

 

Home Information:

Last Name: First Name: Middle Initial:
Home Street Address: Apt #: Bldg #:
City: State: Zip Code:
Home Phone: Sex (M/F):
Email Address:
Nearest intersection to your home: and

Work Information:

Company Name:
Company Street Address: Suite #:
City: State: Zip Code:
Department: Mailstop:
Main Phone: Direct Phone or Extension:
Nearest intersection to your work place: and

Work Hours:

Start Time: AM PM

End Time: AM PM

Days that you work: (check all that apply)

Mon Tues Wed Thurs Fri Sat Sun

Can you arrive and/or leave work within 15, 30 or 45 minutes of your scheduled time? Yes No

If you answered YES to the above question, check one of the following: 15 30 45

Matching Information: (check all that apply if you are interested in being matched)

For CARPOOLING I will:    
Drive Only Ride Only Share driving
     
For VANPOOLING I will:    
Drive Only Ride Only Share driving

Commute Information:

Mark the NUMBER of days per week you use each of the following methods of transportation to get to work:

Carpool/with how many other people?

Vanpool/with how many other people? Primary Driver

Bus
Walk
Bike
Telework

How long have you used your current method of commuting? Years Months

Additional Information:

How did you learn about Bay Area Commuter Services?

Would you like to receive Bay Area Commuter Services' Electronic Newsletter? Yes No

If YES, please list your email address: