Volunteer Driver Registration Form
Thank you for your interest in making a difference in the lives of others
Date
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
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Full Legal Name
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First Name
Last Name
Date of Birth
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Year
2 digit month, 2 digit day, 4 digit year
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Driver's License Number
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Driver's License Expiration Date
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2 digit month, 2 digit day, 4 digit year
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Vehicle Type
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Make and Model
Color
Vehicle Plate Number
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Insurance Company
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Liability Coverage Limits per Person/per Accident
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Please indicate when you may be able to drive
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Rows
Monday
Tuesday
Wednesday
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Friday
Morning
Afternoon
In signing this document, I understand and agree to the following statements:
1. I hereby certify that the above information is accurate and complete to the best of my knowledge. 2. I hereby state that I am currently carrying Automobile Liability Insurance with a minimum coverage limit of $250,000 per person/$500,000 per accident. 3. I am aware that my automobile insurance is primary coverage. If I should be involved in an accident for which I am deemed at fault, my policy will be used first. If the policy limits are exhausted, then Help At Your Door’s insurance may cover the remaining loss. 4. I give permission to Help At Your Door to conduct a driving record check. 5. I am, to the best of my knowledge, free from any physical or medical condition which would impair my ability to drive safely.
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Date
*
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
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Email
Submit
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