Trillium Academy Volunteer Sign up Form

Please complete all steps below. Additionally, we require the following to be uploaded to this form or delivered to our business office:

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 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:

Date

Vehicle Year / Make / Model:

Vehicle License Plate # & State (if other than WA):

# of Students that can be Transported:

# of students that you can transport:

Auto Liability Insurance Carrier:

Insurance Co. Phone #

Please enter a valid phone number.Format: (000) 000-0000.

Insurance Co. Phone #:

Insurance Policy #:

Insurance Expiration Date:

Date

I am at least 18 years of age and with 2+ years of driving experience.

I have a valid Washington State driver's license.

I have an active auto liability insurance policy (policy information provided above) that carries a minimum liability limit of $25,000 per person/$50,000 per accident and $100,000 property damage. The policy includes coverage for general liability, bodily injury, property damage, and uninsured/underinsured motorists (for use when driving students in your personal vehicle)

I certify that my vehicle has no known mechanical defects, and no known safety deficiencies

I certify that all occupants of any vehicle I use to transport students will be required to individually wear a seat belt, including both the driver and passengers. If the vehicle I am driving to transport students is equipped with a passenger side air bag, I will not allow any student to ride in the front passenger seat if they are less than 12 years old, or weigh less than 100 pounds.

I understand that I may only transport students in vehicles with a rated capacity of 10 passengers, including the driver, or less. Any vehicle with a greater than 10 passenger rated capacity is prohibited.

I understand that I must provide a Driver's Abstract from the Department of Motor Vehicles if driving more than one day back-to-back.

I agree to immediately report to the Head of School any and all accidents, regardless of how minor, that I am involved in while transporting staffulty, volunteers, or students.

I certify that I have no known medical conditions that would adversely affect my ability to safely transport students in a motorized vehicle.

I have had a moving vehicle violation(s) within the last four (4) years.

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 have already completed a Washington State background check form for Trillium Academy.

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.

1. Have you ever been convicted of ANY crime? (Convicted includes ALL instances in which a finding of guilty, a plea of guilty or nolo contendere, an Alford plea, or stipulation to the facts is the basis of conviction and/or all proceedings in which prosecution has been deferred or a sentence has been suspended or deferred).

2. Have you ever been convicted of a crime relating to DUI or drugs?

3. Have you ever been convicted of a crime relating to abuse, neglect, sexual abuse, exploitation, or physical abuse?

4. Have you ever been convicted of a crime relating to financial exploitation, including extortion, theft, robbery, or forgery?

5. Do you currently have any outstanding criminal charges or warrants against you in WA or in any other state or country?

6. Have you ever been convicted of domestic violence or assault?

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.)

Gender

Race:

Birthdate (Month/Date/Year - 00/00/0000)

Birthdate

Date

Signature allowing Washington State Patrol background check.

Trillium Academy Driver Authorization