PERSONAL INFORMATION
First Name
*
Last Name
*
Home Address
*
City
*
State
*
- - Choose One - -
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip Code
*
Phone
*
E-mail
*
WORK / SCHOOL INFORMATION
Employer or School
*
Employer or School Address
*
City
*
State
*
- - Choose One - -
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip Code
*
Transportation Mode
*
Carpool
Vanpool
Bicycle
Bus
How did you hear about Guaranteed Ride Home?
*
Brochure
Web search
Facebook
Twitter
Employer or school
Transit provider
Word of mouth
If you are unable to pay for a ride in advance, contact RideshareKC staff at 816-842-RIDE (7433) between 8 a.m. and 5 p.m. Monday through Friday, or email
Rideshare@marc.org
.
*
I am over 18 years old and have read the rules and regulations of the GRH program.
I recognize that I will not be reimbursed in the case of fraudulent use of the GRH program.
For security, type the code you see
*