Driver Waiver Form

Driver Waiver Form
Reason for use / Event name:

Reason for useEvent name
Department / Supervisor:

DepartmentSupervisor
Date

MonthDayYear
Date
Name of driver:

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Driver Waiver Form
I, First Name* Last Name* ,(Printed name - as shown on driver's license) agree and acknowledge the following:
- I declare that I have a valid California driver's license.
- I agree to notify Virna Albrecht (email valbrecht@vfassembly.org or call (760)243-4343 extension 1007) in the event that my driver's license becomes invalid.
- I declare that in the last three years, I have had no more than one chargeable incident and there are no major violations on my record. A chargeable incident is defined as a moving violation or an at fault accident. A major violation is defined as driving under the influence, reckless driving, felony hit and run, and any other incident that invoked more than three points on your driving record.
- I am not aware of reason (medical, behavioral, skills, or otherwise) that would disqualify me from driving on behalf of the church. I am aware that it is against the law to drive while using a cell phone without a wireless hands free device/set-up, and will obey the law at all times.
- I declare that I currently carry automobile insurance coverage for liability, property damage, uninsured motorist, and medical.
- I understand and accept that in the event of an accident my insurance will be primary.
- I understand and accept that the church/school will not provide or cover physical damage coverage in any way.
- Property damage to my vehicle or the contents within are my responsibility. I understand that I am not able to take children of other parents in my vehicle without prior approval/only in the case of an emergency.
Signature
Date

MonthDayYear
Date