Volunteer Nutrition Driver Application
Please take a few minutes to complete the information form below.

Personal Information
Name:
Date of Birth:
Address:
City: State: Zip:
Mailing Address if different than above:
Home Phone: Best Times to Call?
Work Phone: Best Times to Call?
Cell Phone:
E-mail:
Emergency Contact:
Phone:
Relationship to yourself:
Do you speak a language other than English? Other language:
Have you completed any Defensive Driving Classes? (for example: 55 Alive or AAA) Please state type of class and date completed:
How did you hear about our program?

Personal Character Reference

Name:
Address:
Home Phone: Work Phone:
Relationship
How long have they known you?

Days/Times Available

Please enter your availability in the boxes below for the days of the week you would be interested in driving.  If there are certain time periods in which you wish to volunteer, please note those as well.  We are extremely flexible – you drive as little or as often as you’d like, choosing the days, times and areas that work for you.  Please remember, you are not committed to the days and times you indicate below.  As your schedule changes you may change your availability, even from one week to the next!  And if you are not available to drive for a week, or several weeks, or a month, or even several months, just let us know.
Monday:
Tuesday:
Wednesday:
Thursday:
Friday:
Saturday:
Sunday:
How many rides per week are you willing to provide?
Please note that most rides take three to four hours of your time.
Are you willing to take a folding wheelchair?
Clients must be able to self transfer in and out of your vehicle with minimal assistance.  We do not allow any of our volunteer drivers to do actual lifting or bearing of weight.

Service Area

I am willing to serve persons who live in the following geographic areas:
I am willing to drive these persons to the following geographic areas:

Driving Record

In the past 3 years, have you been involved as a driver in an automobile accident?  If yes, please explain:
Have you been convicted during the last 10 years of eluding a police vehicle, reckless (negligent) driving, vehicular assault/homicide, hit & run felony, more than one accident in a 3 year period, driving while intoxicated or under the influence of drugs?  If yes, please explain:

Vehicle Information

Vehicle 1 Year: Make: Model: Color:
Doors (2, 4, truck, van): Air bags?   License #:
Vehicle 2 Year: Make: Model: Color:
Doors (2, 4, truck, van): Air bags?   License #:

License Information

Drivers License Number: Expiration Date:
How long have you had a driver’s license?
Are there any restrictions on your license?   If restricted, state type and date of restriction:
Have you ever had your driver’s license suspended, revoked or refused?  If yes, please explain:

Insurance Information

Automobile Insurance Company:
Types and amount of coverage you have:
Bodily injury:
Property damage:
Medical/personal injury:
Underinsured coverage:
Expiration or renewal date for policy (month and year):
Has an insurance company ever refused, cancelled, non-renewed or given notice of intention to non-renew automobile insurance to you?  If yes, please explain:
Senior Services’ provides excess liability insurance coverage at no cost to you when you are doing assigned volunteer work.  This coverage includes $1,000,000 of Auto Liability insurance and $5,000,000 in umbrella liability insurance.  Complete information describing the coverage will be included in your orientation materials.

Senior Services Home