Trillium Academy Volunteer Sign up Form

Trillium Academy Authorization to Transport Students Form
Those wishing to drive for Field Trips must complete the form below and also provide to our business office or upload below:

1) copy of your current driver's license;

2) copy of your current Proof of Insurance card

If you have any questions please contact office@trilliumacademy.org.
Full Name of Driver

First NameMiddle NameLast Name
E-mail
example@example.com
Phone Number
Format: (000) 000-0000.
Emergency Contact Name

First NameLast Name
Phone Number for Emergency Contact
Please enter a valid phone number.Format: (000) 000-0000.
Driver's License # (and State)
Driver's License Expiration Date:
Vehicle Year / Make / Model:
Vehicle License Plate # & State (if other than WA):
# of Students that can be Transported:
Auto Liability Insurance Carrier:
Insurance Co. Phone #:
Insurance Policy #:
Insurance Expiration Date:
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
If "yes" list was answered above please list the violations and dates

Please note that no person shall be authorized to transport students for Trillium Academy, if in the preceeding four year (4) period, has been convinced or cited by lawful authority for the following:

DUI / DWI	More than Two Citations in a 3 year period
Deferred Prosecution	Suspended License - Moving and Administrative Action
Negligent Driving	Failure to Appear
Reckless Driving	Vehicular Homicide
Open Container Violation	Vehicular Assault
Speeding (11 MPH or more)	Road Rage
Violating License Restrictions	Hit and Run Driving
Illegal Drugs	Other Citations (as deemed appropriate)

I certify that I have answered all the above questions truthfully and have not withheld any information.

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Date

MonthDayYear
Date
Washington State Patrol Check and Declaration

In accordance with RCW 43.43.830, staffulty applicants and prospective volunteers are required to complete this disclosure form. Trillium Academy conducts routine Washington State Patrol background checks on all volunteers and staffulty members. For the safety of our children, all volunteers must complete this form and be cleared through the Washington State Patrol Criminal History (WATCH) program. By signing this application, you grant Trillium Academy permission to conduct the background check, attest to the accuracy of the information provided, and hold Trillium Academy harmless for the results. If you do not sign below, we cannot process your request and you will not be able to volunteer. WSP results are available upon request.
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
7. Have you ever had findings made against you for domestic violence, abuse, sexual abuse, neglect, exploitation or financial exploitation of a child or a vulnerable adult in any civil adjudicative proceeding? (A civil adjudicative proceeding includes a judicial or administrative proceeding as well as findings by the Department of Social and Health Services or the Department of Health that you have not administratively challenged or appealed.)

YesNo
FemaleMaleOther
Race:
Birthdate (Month/Date/Year - 00/00/0000)
Signature allowing Washington State Patrol background check.

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Upload Picture of Front of Driver's License

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Upload Picture of Back of Driver's License

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Upload Copy of Current Proof of Insurance Card

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Driver's License Number & State
Should be Empty:

Trillium Academy Authorization to Transport Students Form