Authorization to Release Information from RideConnect to TRA Group

Authorization to Release Information from RideConnect to TRA Group
Dear RideConnect Client,

We want to make sure your rides continue smoothly during our transition to TRA Group. To learn more about TRA Group, click here.

By signing this form, you are giving RideConnect permission to share the information TRA needs to schedule and provide rides for you.

The information to be shared includes:
- Your name
- Your contact information (address, phone numbers, email if you have one)
- Your demographic information, including your date of birth
- Your emergency contact information
- Your ride requests, including past and upcoming rides
- Notes in your file related to transportation or scheduling
- Forms or paperwork you have signed for RideConnect
We do not have medical records or clinical files, and none will be shared.

Information will only be used to support your transportation services.
Please check the box to authorize sharing:*

I give permission for RideConnect of Family Services of Westchester (FSW) to share my information with TRA Group so that transportation services can continue.
Your Name*

First NameLast Name
Your Phone Number*
Please enter a valid phone number.
Your Email Address (optional)
example@example.com
I hereby voluntarily and of my own free will relinquish and waive the right to make any claims or bring any legal action against TRA or their officers, officials, consultants, contractors, employees and /or volunteers, for any injuries, damages, charges or expenses, including attorney's fees which might be sustained as a result of my voluntary participation in the TRA Program. I also acknowledge that TRA reserves the right to refuse transportation service to anyone in non-compliance with the policies and procedures governing this program. TRA also reserves the right to modify the terms and conditions of this program without prior notice.
Please check the box to agree*

I have carefully read and understand this waiver and fully understand its contents. I am aware that it contains a release of liability and sign it of my own free will.
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