Emergency Ride Home Program (ERH) Registration Form Click here for a printable PDF version of the ERH Registration Form. Name: Phone Number: Home Address: City: Home Zip Code: Email Address: Employer: Address: City: Work Zip Code: Work Phone Number: Work hours From: Work hours To: Estimated miles from home to workplace (one way): Current means of alternate transportation (i.e. transit, vanpool, bike, walk, carpool, etc.): Note: You must use alternate transportation at least 3 times a week to be eligible to use the ERH Program. If you participate in a carpool or vanpool: Driver's Name: Phone #: PERSONAL INFORMATION NOTICE: Pursuant to the Federal Privacy Act (P.L. 93-579) and the information Practice Act of 1977 (Civil Code Sections 1798, et seq.), notice is hereby given for the request of personal information by this form. The requested personal information is voluntary but, to enter into the ERH program this information is necessary. The principal purpose of the voluntary information is to promote ridesharing. The failure to provide all or any part of the requested information will exclude applicant from the ERH program. Disclosure of personal information will be made to carpool matches and also as permissible under Article 6, Section 1796, 17 of the IPA of 1977. Each individual has the right, upon request and proper identification to inspect all personal information in any record maintained on the individual by an identifying particular. Direct any inquiries on information maintenance to your IPA Officer. Emergency Ride Home Program Release and Waiver of Liability 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, request to register my participation in the ERH Program. I hereby assume full responsibility for all risk of injury or loss, including death, which may result from my participation in this program. I agree to hold harmless, release, waive, forever discharge and covenant not to bring suit or claim against San Joaquin Council of Governments, Stanislaus Council of Governments or Merced County Association of Governments, Dibs, or its officers, agents and/or employees from any and all claims and demands which the undersigned may have against the said agency, officers, agents or employees, by reason of any accident, illness, injury or death, or damage to or loss or destruction of any property arising or resulting directly or indirectly from my participation in the ERH Program and occurring during such participation, or any time subsequent thereto, whether or not such loss, injury or death is caused or alleged to be caused in whole or in part by the negligent acts or omissions of the agency, their officers, agents or employees. The terms of this release shall serve as a release and assumption of risks for my heirs, executors, administrators, and for all of my family members. I, the undersigned, acknowledge that I have read the foregoing two paragraphs, and agree to the conditions outlined above. First Name: Last Name: Date: This Registration and Release of Waiver of Liability must be on file prior to participation in the Emergency Ride Home Program. Return completed form to: Dibs, 555 E. Weber Ave., Stockton, CA 95202Or fax to (209) 235-0601 Dibs is a program of the San Joaquin Council of Governments, Stanislaus Council of Governments, and Merced County Association of Governments.