Volunteer Application – Senior Rides And More

Name *

First

Last

Gender *

Male
Female

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Date Of Birth *

Driver's License Number *

State Issued *

Home Phone

Cell Phone *

Email *

Emergency Contact *

First

Last

Phone Number *

Employer

Church/Congregation

Do You Agree To Volunteer For One Year *

Yes
No

Have You Had A Covid Vaccine *

Do You Have Any Physical Conditions That May Limit Your Volunteering?

Personal Reference *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Relationship *

I Confirm That I Am In Good Mental And Physical Health. I Have No Known Infectious Or Chronic Conditions That May Endanger The Elderly, Frail, And Health Impaired Whom I Plan To Serve. I Agree To Notify The Senior Rides Office Should I Become Unable To Perform The Duties Of A Volunteer Due To Mental Or Physical Health Situations In My Life. I Also Understand That All Information Concerning My Health And Mental Status Will Be Considered Confidential In Nature By Senior Rides And More. *

Yes
No

Have You Ever Been Convicted Of A Violation Of Any Traffic Laws *

Yes
No

AUTOMOBILE INFORMATION *

My signature below certifies that the information given on this form is true and correct to the best of my knowledge and that I agree to the following:
I understand that driving for Church ministry is an important responsibility and I will exercise care and due diligence while driving.
I understand that as a volunteer driver, I must be 21 years of age.
I certify that I possess a valid driver’s license and have the proper and current vehicle license and registration.
I certify that I have the required insurance coverage in effect on the vehicle I will be driving for the event.
I understand that I will be using my own personal vehicle to drive care receivers to their appointments.
I agree that I will refrain from using a cell phone or any other electronic device while operating my vehicle.
I agree to adhere to the State of Texas safety belt laws and regulations.
I certify that the level of insurance on my vehicle is consistent with the liability limit requirements of the State of Texas ($30,000/$60,000/$25,000), however we recommend $100,000/$300,000/$50,000 for your own protection.

Signature *

Date *

VOLUNTEER AGREEMENT *

Signature *

Date *