MyRIDE Intake Form

1
Name* This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
3
Phone Number* This field is required.
Please enter a valid phone number.
4
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Are you 55+ in age* This field is required.Not a requirement to drive, but indicates eligibility for RSVP Seniors benefits
Please Select
Please Select
Yes
No
6
Do you have a vehicle with comprehensive insurance?* This field is required.Please ask Jenni if you need help determining
YESNO
7
Veteran Status* This field is required.Are you a veteran
YESNO
8
Demographic Data* This field is required.Please self-identify
American Indian
Asian
Black
Caucasian (white)
Hispanic/Latin
Middle Eastern
More than one race
Other
9
File Upload* This field is required.Please upload a photo of your photo ID/Drivers License (you may take a picture of this item as well)
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
10
File Upload* This field is required.Please upload Insurance Declaration Page (you can take a picture or screen shot of this information as well).
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
11
Availability* This field is required.Please select all days of availability. Our hours of operation are 8:00 AM to 5:00 PM Monday to Friday
Monday
Tuesday
Wednesday
Thursday
Friday
Schedule varies- check in with me weekly
12
Emergency Contact Name* This field is required.
First Name
Last Name
13
Emergency Contact Phone Number* This field is required.
Area Code
Phone Number
14
Service AreaPlease indicate where you are willing to drive
Racine City
Racine county - all
Burlington
Union Grove
Milwaukee
Kenosha
15
Background Check RequiredPlease read and save. You do NOT need to fill out the form.
16
Waiver of Liability and Photographic release* This field is required.The Volunteer hereby releases the Volunteer Center of Racine County (the “Nonprofit”), a non-profit community organization organized and existing under the laws of the United States as a Section 501(c) (3) tax exempt corporation, as well as each of its directors, board members, officers, employees, agents, and other volunteers, from any and all liability associated with participating in any activities as they relate to the Nonprofit. I, the above-named Volunteer, do hereby give my consent to participation in all activities of the Nonprofit. The Volunteer understands that the scope of the Volunteer’s relationship with Nonprofit is limited to a volunteer position and that no compensation is expected in return for services provided by Volunteer; and that Nonprofit will not provide any benefits or rights traditionally associated with employment to Volunteer. The Volunteer desires that the Volunteer engage in activities related to serving or participating in the Nonprofit’s activities as a player, participant or volunteer. The Volunteer is responsible for the Volunteer’s own insurance coverage in the event of personal injury or illness as a result of participation in activities of the Nonprofit. The Volunteer waives all legal rights that he or she may have if he or she were an employee of Nonprofit, due to his or her status as a volunteer. 1. Waiver and Release: I release and forever discharge and hold harmless Nonprofit and its successors and assigns from any and all liability, claims, and demands of whatever kind or nature, either in law or in equity, which arise or may hereafter arise from the activities as a Volunteer with the Nonprofit, including claims arising out of negligence. I understand and acknowledge that this Release Discharges Nonprofit from any liability or claim that I may have against Nonprofit with respect to bodily injury, personal injury, illness, death, or property damage that may result from the services the Volunteer provides to Nonprofit or occurring while Volunteer is providing volunteer services. 2. Insurance: I affirm that I am covered by primary medical insurance and understand that I am responsible for my medical bills if injury occurs. Further, I understand that Nonprofit does not assume any responsibility for or obligation to provide the Volunteer with financial or other assistance, including but not limited to medical, health or disability benefits or insurance of any nature in the event of the Volunteer’s injury, illness, death or damage to his or her property. I expressly waive any such claim for compensation or liability on the part of Nonprofit beyond what may be offered freely by Nonprofit in the event of such injury or medical expenses incurred by the Volunteer (which the Nonprofit is under no legal duty to provide). 3. Assumption of Risk: I understand that the services provided by me to Nonprofit may include activities that are inherently dangerous to me, including but not limited to lifting, walking, standing, bending and other physical activities. I hereby expressly assume the risk of injury or harm to me from these activities and hereby release Nonprofit from all liability incurred from or for injury, illness, death, or property damage resulting from the services I provide as a volunteer or occurring while I am participating in events. 4. Photographic Release: I, grant and convey to Nonprofit all right, title, and interests in any and all photographs, images, video or audio recordings of the Volunteer or his or her likeness or voice made by Nonprofit in connection with the Volunteer participating in Nonprofit events, including but not limited to, any royalties, proceeds, or other benefits derived from such photographs or recordings. 5. Medical Treatment: I hereby release and forever discharge Nonprofit from any claim whatsoever which arises or may hereafter arise on account of any first-aid treatment or other medical services rendered in connection with an emergency during my tenure as a volunteer with Nonprofit. I give my consent for the Nonprofit to provide, administer, or obtain medical treatment for me. 6. Other: I expressly agree that this Release is intended to be as broad and inclusive as permitted by the laws of the State of Wisconsin and that this Release shall be governed by and interpreted in accordance with the laws of the State of Wisconsin. I agree that in the event that any clause or provision of this Release is deemed invalid, the enforceability of the remaining provisions of this Release shall not be affected. By signing below, I, the above-named Volunteer, express my understanding and intent to enter into this binding Release and Waiver of Liability, knowingly and voluntarily.
Agree
17
Signature* This field is required.Please Review all above information and sign below that you confirm interest in MyRIDE and have read/agree to the waiver of liability and photographic release
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