Form Center

By signing in or creating an account, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.

Emergency Ride Home Program

  1. If you qualify and would like to apply for the Emergency Ride Home service, complete and submit the following application form online. You may also print out and complete the application and fax it to (901) 222-9561 or mail it to the AQIB office.To find out if you qualify, please refer to the Policies & Procedures.

  2. Please check if you work*

  3. Is your rideshare a: *

  4. I hearby attest that I share a ride to my worksite at least three (3) days a week or fifteen (15) days each month with the person or persons named above. I further attest that I have read the policies and procedures of the Emergency Ride Home service and agree to comply with those policies and procedures. I hearby release the Regional Transportation Authority, its officers, board of directors, agents and employees from all liability, claims, suits, demands or damages for personal injury, loss, theft or damage to my personal property; loss of income; or consequential damages resulting from delays or absence of cab or rental car; or termination of the program.

  5. Shelby County Health Department, Air Quality Improvement Branch, 814 Jefferson, 4th Floor, Memphis, TN 38105
    (901)222-9594 Fax (901)222-9561
    johnathan.dugger@shelbycountytn.gov

  6. Leave This Blank:

  7. This field is not part of the form submission.