Skip to Main Content
Do Not Show Again
Coronavirus Disease 2019 (COVID-19)
Report COVID-19 Concerns
How Do I
Select a Category
Aging Commisions Mid South Forms
Air Quality Improvement Branch
Board of Commissioners
Chancery Court Forms
Circuit Court Forms
Criminal Court Forms
Housing Department Forms
IT STEERING COMMITTEE
Office of Early Childhood and Youth
Office Of Preparedness
Office of Re-entry
Public Records Commission
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.
Sign in to Save Progress
Emergency Ride Home Program
This form has been modified since it was saved. Please review all fields before submitting.
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
Nearest major cross street
Round trip miles to work
Please check if you work
What is your normal work schedule?
Is your rideshare a:
Name(s) of people with whom you regularly rideshare
Supervisor's Phone Number
Work Phone Number
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.
By checking this box, you confirm the above statement.
Shelby County Health Department, Air Quality Improvement Branch, 814 Jefferson, 4th Floor, Memphis, TN 38105
(901)222-9594 Fax (901)222-9561
Leave This Blank:
Receive an email copy of this form.
This field is not part of the form submission.
Submit and Print
* indicates a required field
County Office Directory
NACo Prescription Discount Card Program
Slideshow Left Arrow
Slideshow Right Arrow