STUDENT RIDESHARE APPLICATION FORM

Please Print and Fill out form

Name ____________________________________________

Male _______  Female ______

Application for Semester:

Summer 20___  Fall/Winter 20____  Spring 20_____

Where I Live – Street Address (No P.O. boxes or route
numbers, please)

_________________________________________________

City ______________________________________________

State _______________     Zip ___________

Home County ______________________________________

Home Telephone  __________________________________

Cell: ________________  Fax: ________________

Email: ____________________________________________

Do you have a carpool partner?  YES/NO

If so, what is their name?

_________________________________________________

Who is the Primary Driver in your carpool?

_________________________________________________

Would you like to be contacted at home, by cell phone, or work by others interested in rideshare?

Home _________ Work _________  Neither ________

Nearest major intersections to your home?

_________________________________________________

Nearest major intersections to your school/primary class building?

_________________________________________________

Class Schedule:  Start Time ____________________  am / pm

Stop Time _________________________________  am / pm

How flexible is your schedule?  ______ Not at all  ___   15 Min.

______  30 Min.      ______  60 Min.

How did you hear about UAB’s Student Carpool Program?

_________________________________________________

I am most interested in:  _____ Carpool   _____  Vanpool 

_____  Transit  ______  Biking _______  Walking

I am interested in vanpooling and volunteer to be a: 

_____ Driver_________ ___Backup Driver ____Passenger Only

Registered UAB Rideshare Program participants are eligible foran emergency ride home in the event of an emergency.

Register me for the Emergency Ride Home
(emergency transportation):  n YES    n NO

Student Agreement and Participation Form

I, the undersigned, acknowledge that I have read, understand, and will abide by the rules of the CommuteSmart Carpool Chal­lenge as specified in the Program Guidelines.  Further, I acknowledge and understand that inappropriate use of this service or failure to abide by the Program Guidelines will result in forfeiture of any claim for financial incentive for participating students of University of Alabama at Birmingham.

I, the undersigned, acknowledge and understand that participation in the University of Alabama at Birmingham Student Carpool Program, the CommuteSmart Rideshare Carpool Challenge, and other Rideshare Programs is solely voluntary and that my participation does not in any manner imply that I am acting in the course and scope of official UAB business, nor does it in any ­manner establish a university-student, employer-employee, or agency-student relationship with the University of Alabama at Birmingham, CommuteSmart Rideshare, VPSI Inc., or the Regional Planning Commission of Greater Birmingham. I acknowledge that it is the responsibility of myself and/or the owner of the vehicle to provide adequate liability insurance in accordance with the State of Alabama Mandatory Automobile Insurance Law.

I, the undersigned, fully understand and upon affixing my sig­nature request permission to participate in the UAB Student Rideshare Program whose administrative and programmatic services are supported by the CommuteSmart Rideshare Program, and do hereby assume full responsibility for liability and all risk of injury or loss including death, which may result from my participation in this program and hereby agree to hold harmless, release, waive and forever discharge and covenants not to sue or bring claims against the my Employer, CommuteSmart Rideshare Program, VPSI Inc., or the Regional Planning Commission of Greater Birmingham, their officers, agents and/or employees from any and all claims and demands whatsoever which I, the undersigned, or any third party and representative thereof may have against the University of Alabama at Birmingham, CommuteSmart Rideshare Program, VPSI Inc., my Employer, or the Regional Planning Commission of Greater Birmingham, its officers, agents and/or employees by reason of accident, illness, injury or death, or damage to or loss of property arising or resulting directly or indirectly from my participation in the UAB Student Carpool Program.

_________________________________________________

SIGNATURE                                                      DATE

Please mail or fax your Rideshare Application to: UAB Parking and Transportation Services 608 8th Street South, Birmingham, AL 35294-4550 or fax to: (205) 975-9529