Carpool / Commuter Update Form

* I am updating an existing carpool with the following changes:

Update my contact info (new address, email, phone)

Add a Rider

Removing a Rider

Ending the Carpool

Carpool Number:

* Carpool Coordinator's Name:

* Rider's First Name

* Rider's Last Name

*

Male

Female

* Street Address

Address Line 2

* City

* State

* Zip Code

Home Phone

* Email Address

* Worksite

* Work Phone

* Start Work

*

AM

PM

* End Work

*

AM

PM

* # Days Carpooling per Week

* Miles Traveled to Work (One Way)

Participation Agreement
HART reserves the right to verify carpool activity by participants through random checks at commuter worksites. Any fraudulent use of the program will result in immediate dismissal of the carpool from the program and voids provision of any or all program incentives.

I understand that my participation in a carpool is voluntary. In consideration of registration in the program, I waive, release, and discharge HART Commuter Information Services from any incident that may arise from my participation in the carpool.

This waiver, release and discharge, extends to all members of HART Board of Directors, Staff, Members, and Associates of HART.

* YES

I agree to all of the above terms and conditions.

Comments

* Indicates Response Required