Emergency Ride Home Registration

Review and comply with the ERH Guidelines before registration.

You must be registered at least 3 days before you are eligible for ERH Reimbursement.

Please note: By filling out this form and registering for the Emergency Ride Home Program, you consent to being enrolled in NorCal Go.

Name

Phone

Home Adress

City

Zip Code

Employer

Work Adress

Work Phone

Work Hours

Estimated Miles from Home to Workplace (One Way)

Alternate Transportation Mode (train, bus, vanpool, carpool, walk, bike)

Carpool or Vanpool Coordinator's Name

I, the undersigned, recognize that participation in the Dibs Emergency Ride Home (ERH) program is strictly voluntary and that such participation does not imply that I am acting in the course and scope of official company business. I, the undersigned, hereby agree that participating in the ERH program does not come without risk of injury or harm, including, but not limited to road hazards, risks inherent in driving, or being a passenger. I, the undersigned, hereby accept full responsibility for my own safety, and assume all risk of loss, property damage, or personal injury, including death, whether foreseen or unforeseen, that may sustain as a result of participating in the ERH program. I hereby agree to hold harmless SJCOG, its officers, directors, employees, attorneys, agents, and contractors from and against any liability, demand, claim or right of action for any damage or injury, including death, to any person or property. In no event shall SJCOG be liable for any damages, losses, or claims, including without limitation, direct, indirect, incidental, special consequential, or punitive damages, arising out of your participation in the ERH program. I, the undersigned, acknowledge that I have read the foregoing two paragraphs, and agree.