Volunteer Application

Name *

First

Last

Gender *

• Male
• Female

Address *

Address Line 1

Address Line 2

City

--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

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 *

• First Vaccine
• Second Vaccine
• First Booster
• Fully Vaccinated
• Not Vaccinated

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

Personal Reference *

First

Last

Address *

Address Line 1

Address Line 2

City

--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

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 *

Clear Signature

Date *

VOLUNTEER AGREEMENT *

• Keep all information concerning my care receiver(s) confidential.
• Do not offer the care receiver financial advice.
• Do not offer medical advice; instead, instruct the care receiver to call their physician or call the Senior Rides office if you have any concerns about the health of the care receiver.
• Do not accept any form of compensation, gifts of value, or money from the care receivers for services associated with Senior Rides.
• Do not use knowledge gained through volunteer services for personal profit, or for friends or family.
• Respect the beliefs of the care receiver(s) – we respectfully request you not try to convert any care receiver to another belief system.
• Observe scheduled times of requests and call the care receiver the evening before a scheduled ride.
• Notify the Senior Rides office as soon as possible if I am unable to report for my scheduled time.
• Follow all instructions as issued by the Senior Rides Director concerning my care receiver.
• Keep records of mileage driven and time volunteered and submit this information to the Senior Rides office at the end of each month.
• Exercise care and be aware of personal safety on all assignments.
• Maintain a pleasing and helpful attitude with all care receivers.
• I affirm that all given information is true, correct, and complete, and I hereby apply to the program and agree to abide by all program rules.
• I hereby give my consent for Senior Rides and More to contact my references and/or employer; and to conduct a routine background check

Signature *

Clear Signature

Date *

Submit