Parking Registration & Payroll Authorization Form/
Attestation of No Parking

Please select one:

I park at the Valhalla campus or at certain leased or owned locations near the Valhalla Campus (including but not limited to: 19 Bradhurst Avenue and 7 Skyline Drive).I do not drive to work (I take public transportation, taxi service, receive a ride to campus from others, or walk to campus).I drive to work, but am based at another campus or at an off campus location other than those covered by policy HR-6A.

Please provide location:

EMPLOYEE INFORMATION

First Name:

Last Name:

Phone Number:

Email Address:

Title:

Department:

Work Shift:

Primary Work Location:

Direct Supervisor Name:

ID Number:

See Images Below

Badge Number:

See Images Below

VEHICLE INFORMATION

Year:

Make:

Model:

License Plate Number:

State Registered:

Other:

MONTHLY FEE and START DATE

Start Date:

The current monthly fee is $20. There is a one-time parking registration set up fee of $10. Please Note: The first month's fee will be prorated to $10 (plus the set up fee) only for applications received on the 15th of the month or later.

I understand and agree to the fees stated above.

The WMC Parking Policy (HR-6A) can be viewed by clicking here.

ACKNOWLEDGEMENT OF TERMS AND E-SIGNATURE

Staff must only park in the lot/area assigned by the parking office. Staff are entitled to one parking space. Vehicles parked over stall lines will be issued a warning citation for the first violation. Upon issuance of a second citation, vehicle may be towed at Westchetser Medical Center's discretion. Vehicles impeding access or creating dangerous situations may be removed without additional notice. Westchester Medical Center does not guard or assume care, custody, or control of your vehicle or its contents, and is not responsible for loss by fire, damage, or theft. ARTICLES LEFT IN CARS ARE THE STAFF'S SOLE RESPONSIBILITY. REMOVE ALL VALUABLES FROM SIGHT AND LOCK YOUR CAR.

Staff are required to keep vehicle and contact information current and MUST provide updated vehicle information, as applicable (make, model, year, license plate).

This agreement is made by and between Staff and Westchester Medical Center, its legal representatives, heirs and assigns: Employee agrees that no third party shall be held liable for the performance of any of the terms of this agreement except as shall otherwise be provided by law. Failure to follow instructions from parking management personnel may result in revocation of parking privileges. All Staff parking on site are subject to WMC policy HR-6A "Parking Operation for Staff" and any other policies that govern parking on or near the Valhalla campus.

I hereby authorize Westchester Medical Center to withhold from my paycheck my parking fees. I authorize the deduction of my monthly parking fee on a pre-tax basis, as well as all late fees or additional parking fees. This shall include any future increases to the monthly parking fee. If I have a balance that pre-dates this agreement, I acknowledge that this may also be collected via a payroll deduction. This authorization will remain in effect until all amounts due have been paid.

I acknowledge that it is mandatory to be enrolled in payroll deduction for parking fees and cannot cancel this authorization if I remain on the payroll of Westchester Medical Center or its affiliates, and continue to utilize parking services in any manner described by WMC's parking policy. Cancellation, if applicable, shall not cancel any payments due for the prior parking period.

I also understand that I am responsible for payment of all fees related to parking and agree to pay all fees by check, credit card or other means accepted by Westchester Medical Center if my deduction is delayed or if Westchester Medical Center is unable to receive the full amount owed through payroll deduction for any reason. Westchester Medical Center reserves the right to determine the deduction schedule. Deductions will typically be made at the rate of 50% of the monthly rate in each of the first two pay periods of each month (for a total of 24 deductions per year).

I understand that my electronic signature below has the same force and effect as my written signature.

E-Signature

Date

ACKNOWLEDGEMENT OF TERMS AND E-SIGNATURE

In accordance with Westchester Medical Center's policy regarding parking on campus, all Staff who park their vehicles on the Valhalla campus or at certain leased or owned locations near the Valhalla campus (including, but not limited to, 19 Bradhurst Avenue and 7 Skyline Drive), must register and pay for parking. Staff includes all full-time, part-time, and per-diem WMCHealth network employees, volunteers and house staff, members of the medical and allied health staff, and contracted personnel providing services on the Hospital campus or its leased or owned locations. If you are a member of Staff currently working in any of the above referenced locations, you must be registered with the Hospital's parking service -- please choose the first option above to complete your registration. Otherwise, please review and acknowledge the following:

I understand that all Staff who park on the Valhalla campus or its leased or owned locations must register and pay for parking. I confirm that I am not parking a vehicle on the Hospital's campus, 19 Bradhurst Avenue, or 7 Skyline Drive. I understand and agree that if my situation should change and I require the use of parking as defined in the policy, I must immediately register and pay for parking. I acknowledge that if I am based at another campus or an off-site location not covered by the policy, and my role regularly requires attendance (and parking) at the Valhalla campus or any of its leased or owned locations four or more times per month, that I must register for parking. Failure to do so may result in disciplinary action.

I understand that my electronic signature below has the same force and effect as my written signature.

E-Signature

Date