RTA Emergency Ride Home Application

If you qualify and would like to apply for the Emergency Ride Home service, complete and submit the following application form online. You may also print out and complete the application and fax it to (615) 880-3297 or mail it to the RTA office. If you are unsure whether you qualify, please refer to the Policies & Procedures.

Name (first & last):
Home Address 1:
Home Address 2:
City:
State:
Zip:
email address (if you have one):
Nearest major cross street:
Home Phone:
Work Phone:
Resident County:
Round trip miles to work:
Please check if you work:	Flexible hours     Saturdays     Sundays
What is your normal work schedule?
from AM PM to AM PM
If you work another shift, tell us the hours:
from AM PM to AM PM
Do you need riders?	Yes    No
Please refer to the Emergency Ride Home Policies & Procedures to find out if you are eligible for a cab or a rental car.
Employer Name:
Employer Address
Employer Address 2
Supervisor's Name:
Supervisor's Phone:	()
Work Phone:	()
Work County:
Is your rideshare a:     Vanpool      Express Bus Route (enter route number) Choosing the Express Bus Route option will disable fellow riders fields below. Proceed to the "Additional comments/questions" area.
Name(s) of people with whom you regularly rideshare:
Current Driver's Name:      Work Phone: (  )  Back-up Driver's Name:      Work Phone: (  )  Rider 1 Name:      Work Phone: (  )  Rider 2 Name:      Work Phone: (  )  Rider 3 Name:      Work Phone: (  )
Other Riders:
Additional comments/questions:
I hearby attest that I share a ride to my worksite at least three (3) days a week or fifteen (15) days each month with the person or persons named above. I further attest that I have read the policies and procedures of the Emergency Ride Home service and agree to comply with those policies and procedures. I hearby release the Regional Transportation Authority, its officers, board of directors, agents and employees from all liability, claims, suits, demands or damages for personal injury, loss, theft or damage to my personal property; loss of income; or consequential damages resulting from delays or absence of cab or rental car; or termination of the program.  By checking this box, you confirm the above statement.
Enter security code: