Carpool Form

CONTACT INFORMATION

First Name *

Last Name *

Home Address (P.O. Boxes not accepted) * Include apt, suite, unit, etc.

City *

Zip *

Mailing Address (if different than above) Include apt, suite, unit, etc.

City

Zip

Daytime Phone (Include any extensions) * Example: 1234567890x123

Email * Please use a valid email address. Follow-up surveys will be sent to this email.

Add my email to receive updates and notices about new programs and promotions. *

ABOUT YOU

Year of Birth *

Gender *

Male
Female

Do you have a valid driver's license? *

Do you own or have access to a vehicle (includes carsharing vehicles)? *

EMPLOYER OR SCHOOL INFORMATION

Employer/School *

Address (P.O. Boxes not accepted) * Include suite, unit, floor, etc.

City *

Zip *

Work Phone (include any extensions) * Example: 1234567890x123. Write N/A if student.

Work/School Email

Occupation *

CARPOOL INFORMATION

Type of Carpool *

Work
School

Students must submit a copy of their current class schedule to verify enrollment.

Choose a file to upload

When did you begin carpooling? (Month/Year) * Example: January 2009

How many people are in your group (including yourself)? *

List your Carpool Partner(s) First and Last Names and his/her Home City * Example: John Smith from Pleasant Hill; Jane Smith from Antioch

AGREEMENTS

I verify the information submitted above is true and correct. I understand I may be asked to provide information to verify the answers I submitted above. *

Agree
Disagree

Release & Waiver of Liability * I recognize that participation in the Carpool Program is strictly voluntary and that such participation is not within the course and scope of my employment or schooling. I request to register my participation in the Carpool Program. I hereby assume full responsibility for all risk of injury and loss, including death, which may result from my participation in the program. I agree to hold harmless, release, waive, forever discharge, and covenant not to bring suit or claim against 511 Contra Costa, TRANSPAC, the City of Pleasant Hill, the Company, or their respective officers, agents, and/or employees from any and all claims and demands which I may have against 511 Contra Costa, TRANSPAC, the City, the Company, or their officers, agents, or employees, by reason of an accident, illness, injury, or death, or damage to or loss of or destruction of any property arising 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 511 Contra Costa, TRANSPAC, the City , the Company, or their officers, agents, or employees. The terms of this release are binding on my heirs, executors, administrators, and for all of my family members as well as myself. I have read the foregoing paragraph and fully understand the terms contained therein and submit this waiver freely and without inducement.

Agree
Disagree

Am I eligible to apply?

What are the program rules?

Carpool Program Application

CONTACT INFORMATION

ABOUT YOU

EMPLOYER OR SCHOOL INFORMATION

CARPOOL INFORMATION

AGREEMENTS