Volunteer Driver Application Form

Transcription

1 Road to Recovery Volunteer Driver Application Form Please Print Name: Street Address: City State Zip: Other Address Information/ Home Phone: Work Phone: Date of Birth: Occupation: Emergency Contact Driver s License Auto Insurance for Vehicle You Plan to Use Days of Week and Hours You Will be Regularly Available to Transport Patients Name: Phone: Number: Expiration Date: Insurance Company Name: Insurance Company Phone: Bodily Injury Limit: Property Damage Limit: Days Available ( ) Monday Tuesday Wednesday Thursday Friday Saturday Sunday State: Class: Hours Available Training Date: Training Location How long have you been driving in this community? Would you be willing to assist in volunteer recruitment? What type of car do you drive? [ ] 2-door [ ] 4-door How many passengers can you safely carry? [ ] 2 [ ] 4

2 Have you been involved in a car accident in the last five years? [ ] Yes [ ] No Have you received a traffic violation (unrelated to parking) in the last five years? If yes, please state the offense for which you were convicted and are now obliged to do community service: Are you volunteering for this program pursuant to any court ordered community service? If yes, please explain: Have you ever been convicted of any type of felony or misdemeanor involving a vehicle? Do you have any health problems which might affect your driving? If yes, please explain: Do you have limitations on where you will drive? [ ] Yes [ ] No Counties Willing to Serve: Distance Willing to Drive: Facilities Willing to Go To: Maximum distance you will drive a patient to treatment: Do you have any limitations on the types of patients you are willing to drive? (e.g., patients who might need some assistance, children with parent or guardian, non-english speaking) How did you hear about this program?

3 What is your reason for volunteering? Previous volunteer experience: Insurance. All volunteers operating personal vehicles (not owned or leased by the American Cancer Society) for the business of the Society become an additional insured under the Society s auto liability policy, but only: In excess of the volunteer s personal auto liability coverage and policy limits To the extent of bodily injuries to third parties and/or physical damage to third party vehicles or property of others. The American Cancer Society automobile insurance policy does not cover bodily injury to the volunteer or physical damage to the volunteer s vehicle. The volunteer is required to maintain minimum required auto liability limits as mandated by the state in which the volunteer drives. The Society further suggests that volunteers: Maintain third party liability limits of at least $100,000 per person bodily injury, $300,000 per accident, and $100,000 property damage Add uninsured/underinsured motorists coverage to their policy Obtain physical damage coverage for their vehicle Maintain personal medical insurance or, through their auto policy, purchase medical payments coverage or personal injury protection (as required by no-fault states) to ensure bodily injury protection for themselves. Please include a copy of your auto liability coverage with your completed application. I hereby apply for service as a volunteer driver. I understand and agree to comply with policies and procedures of the American Cancer Society transportation program, copies of which are available to me at anytime upon my request. Reservation of Right of Refusal. I realize that the American Cancer Society, in its sole discretion, reserves the right to refuse the offer of services of any potential volunteer. Notwithstanding the foregoing, I understand that this refusal shall not be based upon any criteria that would violate either state or federal law, including, but not limited to, color, race, religion, national origin, age, or any other protected classification. Authorization to Release Motor Vehicle Driving Records. I hereby consent to the Department of Motor Vehicles, or other similar agency, to furnish any and all documents and electronic information that it has with respect to my driving history and records, including but not limited to any and all violations of law, to the American Cancer Society as requested by the American Cancer Society from time to time. This authorization shall remain in effect until revoked by me in writing or as limited by applicable state law.

4 All information disclosed by you or otherwise obtained by the Society shall be fully protected in accordance with the Society s privacy and confidentiality policies. Volunteer Applicant Signature: Date Signed: American Cancer Society Staff Use Only Interviewed by (Staff Signature): Date Interviewed: Current Driver s License Verified ( ) Current Liability Insurance Verified ( ) Office Name: Location Name: Office ID: Location ID: Siebel ID: MWD

5 A P P L I C A N T S D i s c l o s u r e & C o n s e n t R E L E A S E O F I N F O R M A T I O N AMERICAN CANCER SOCIETY - VOLUNTEER INFORMATION (Please Print) Account Number: Applicant Name: (First Middle Last) Current Address: (street address) Other Name(s) Used: (like Maiden) City: State: Zip: 2.Other Name(s) Used: Former Address: (1) Social Security No: City: State: Zip: Driver s License No.: State: Former Address: (2) Date of Birth: Place of Birth: (City, State, Country) City: State: Zip: Applicant Instructions: Please read this disclosure and consent form carefully before signing. You will be provided with a copy of this form at any time upon request. DISCLOSURE AND CONSENT CONCERNING CONSUMER REPORTS FOR VOLUNTEER APPLICANTS AND VOLUNTEER PURPOSES. You should read carefully. This consent and release has been provided to you for this organization to request a consumer report or investigative consumer reports in connection with your application for volunteer, resume or during the course of your volunteer affiliation, if any. The Applicant acknowledges that this organization may now, or at any time acting as a volunteer, verify information within the application or resume to volunteer. The verifications and/or checks may include but not limited to: driving record, workers compensation records, credit bureau files, employment references, personal references, any educational and licensing institution and to receive any criminal record information pertaining to me which may be in the files of any Federal, State or Local criminal justice agency in any State. A photocopy or telephonic facsimile (Fax) of this Disclosure and Consent authorization for Release of Information shall be valid as the original. The results of this verification process will be used to determine volunteer eligibility. All results will be kept CONFIDENTIAL. The information obtained will not be provided to any parties other than to designated Personnel of the organization. According to the Fair Credit Reporting Act, if any adverse decision is made with regard to your volunteer application, based entirely or in part on the information contained in a consumer report or investigative consumer report prepared by a consumer reporting agency, you are entitled to receive a copy of this report upon written request, and a disclosure of the nature and scope of the investigative report. Your signature below indicates that you have carefully read and understand that a consumer report or investigative consumer report regarding you may be requested and reviewed for volunteer purposes, including any future decisions concerning your promotion or retention as a volunteer. Additionally, your signature below reflects your understanding that such consent will remain in effect indefinitely until you revoke it in writing. CONSENT STATEMENT I have carefully read and understand this disclosure and consent form and by my signature consent to the release of consumer or investigative consumer reports, as defined above in conjunction with my volunteer application. I further understand this consent will apply during the course of my volunteer activities, and that such consent will remain effect until revoked in a written document signed by me. In the event that I wish to refuse or revoke my consent at any time, I understand that I may do so. I further understand that any and all information contained in my volunteer application, or otherwise disclosed to this organization by me may be utilized for the purpose of obtaining the consumer reports or investigative consumer reports requested by the organization and confirm that all such information is true and correct. I, the undersigned applicant, do hereby certify that the information provided by me for the purpose of volunteer activities is true and complete to the best of my knowledge. I understand that if I am deemed a volunteer, any false statements will be considered as a cause for possible dismissal. I authorize InfoMart and any of its Agents/designated Company Personnel, to disclose orally and in writing the results of this verification process and/or interview to authorized representatives. I do hereby agree to forever release and discharge this company, our agent, InfoMart and their associates to the full extent permitted by law from any claims, damages, losses, liabilities, costs and expenses, or any other charge or complaint arising from the retrieving and reporting of information. ATTENTION RESIDENTS OF CALIFORNIA, MINNESOTA, & OKLAHOMA ONLY: By checking this box, I request to receive a copy of the report from the credit reporting agency at no charge at the same time the report is provided to the prospective employer. APPLICANT: Applicant Signature Date Applicant Name Typed or Printed Phone