ASC Volunteer Driver Application
We often need help in transporting our ASC youth. Our volunteers have been generous in their assistance. The purpose of this form is to
reduce the liability
of ASC and volunteer drivers by being proactive in our selection of volunteer drivers. This form, along with supplemental documentation, is required if you are interested in helping with such needs during the year.
A new Volunteer Driver Application Form must be completed annually. The completed application must be returned along with: A copy of your driver's license. A copy of your current vehicle insurance card
Section 1 – Volunteer Driver Information
Name
*
First Name
Last Name
Primary Phone
*
Format: (000) 000-0000.
Alt Phone
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Driver's License Number
*
State Issued
*
Exp. Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Car Make
*
Car Model
*
Car Year
*
# of Working Seatbelts
*
Please complete your coverage information and amounts for your vehicle:
Insurance Company
*
Policy#
*
Bodily Injury per person liability limit
*
Bodily Injury per accident liability limit
*
Property damage liability limit
*
Uninsured/underinsured motorist coverage?
*
Yes
No
Please note:
ASC requires volunteers to have a minimum amount of liability insurance.
1) $100,000 liability per person for bodily injury
2) $300,000 liability per incident for bodily injury for all vehicle occupants
3) $100,000 liability for property damage
Are you licensed to drive a commercial vehicle?
*
Yes
No
Have you been in an accident in the last 3 years?
*
Yes
No
If you answered yes, please describe the infraction below.
*
Have you been ticketed for moving violations within the last 3 years?
*
Yes
No
If you answered yes, please describe the infraction below.
*
Have you been convicted for DWI/DUI of alcohol or drugs, had your license suspended for moving violations, hit and run, eluding an officer, reckless or negligent operation of a vehicle, or driving while under suspension or revocation in the past 5 years?
*
Yes
No
If you answered yes, list the date and type of ticket (DUI; 10-2-01)
*
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Section II – Requirements for Volunteer Drivers
I certify that for the year
*
1) I possess a valid driver’s license and am providing a copy of my license and the first page of my car insurance policy.
2) I will contact my insurance agent to ascertain if there are any liability policy limits or exclusions regarding transporting other youth that might affect my ability to meet the qualifications of a volunteer driver.
3) I will maintain the minimum insurance coverage required by ASC for volunteer vehicles listed in Section I and only volunteer to drive when such insurance policies are in force.
4) I understand that in case of any type of accident, injury, or vehicle damage, ASC’s liability insurance policy does not provide primary or direct insurance on my vehicle.
5) I will advise ASC of ANY change in information provided on this form including, but not limited to, involvement in a car accident in which I am cited, any citations for moving violations, non-renewal of license, termination of license, change of insurance company, change in amounts of insurance coverage, termination of insurance or change in vehicle.
6) ASC youth riding in my vehicle will be seated and secured with individual working seatbelts and proper child restraints. (No double bucking is permitted.)
7) To my knowledge, my vehicle is in safe operating condition (brakes, tires, etc.)
8) I will notify ASC personnel if I no longer wish to drive or if I wish to be removed from the approved drivers list.
Section III – Declaration and Signature
I affirm that I will carefully transport ASC youth under my care, including obeying all traffic laws. The information given on this form is true and correct to the best of my knowledge.
Signature:
*
Date:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Section IV – Administrative Approval
Approval Status
Approved
Disqualified from addition to ASC's Approved Driver's list.
Administrator Signature:
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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