Senior Rides Mileage Reimbursement form 2016

Senior Rides Program   
Request for Mileage Reimbursement 
 
Driver Name:  _____________________________________ 
    
Driver Address:  ___________________________________     Phone : ___________________ 
 
Senior Passenger Name:  ________________________________   (Please indicate if trips are ONE-WAY or ROUND TRIP) 
 
Date 
Complete Start Address 
Complete Destination Address 
(include Street #) 
*Trip   
Purpose 
Total Miles 
(Completed 
by ECTC) 
Sample 
7/1/15 
20 Goldstar Hwy, Groton 
 
L&M Hospital 
400 Montauk Ave,  New London 
Medical 
Appt. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
    * Trip purpose must be medical trips only.  Return form to your senior center for review and they will forward the form to ECTC. 
 
I as a passenger or driver understand by signing this document that I am releasing the Eastern Connecticut Transportation Consortium, Inc (ECTC), Towns of 
Bozrah, East Lyme, Groton, Griswold, Ledyard, Lisbon, Preston, Stonington, N. Stonington, Waterford, and the City of New London from any responsibility of any 
type of vehicle damage, injury and/or death caused by an accident during the voluntary transport for this program. 
  
I understand that Eastern Connecticut Transportation Consortium, Inc (ECTC), and the Towns of Bozrah, East Lyme, Groton, Griswold, Ledyard, Lisbon, Salem, 
Stonington, N. Stonington, Preston, Waterford, and the City of New London are providing reimbursement of mileage under a  Municipal Grant program allowing 
eligible passengers to chose their own driver. As such, these drivers are not trained or certified, nor have any checks such as safety inspections, verification of 
insurance, license checks or criminal checks been performed. I voluntarily allow this driver to transport me in his/her vehicle with full knowledge that I am riding 
at my own risk. 
  
By signing this document, I am fully aware of all provisions stated above and agree to the terms and attest the above trip information is true:  
           _________________________________        ______________    _________________________________     ________________ 
            Signature   (Driver)                                          Date 
 
    Signature (Rider) 
 
   
  Date 
 
Trips authorized:  ______________________________                        _____________   
                                              Signature  (Senior Center Representative)          Date           
 
Circle Town Affiliation:      Bozrah        East Lyme        Groton         Griswold          Ledyard          Lisbon         New London          
 
 
 
 
 
             N. Stonington      
         Preston           Salem             Stonington       Waterford 
                                                                                                                            
  (FOR ECTC OFFICE USE ONLY) 
 
_______   x   _________________= ____________________ 
 
 Rate     x    Total miles           Reimbursement Cost 
 
 
Total Medical Trips: ________