Volunteer Driver Application To become a Neighborhood Volunteer Driver, please fill out the following form.Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. - Step 1 of 4Name *FirstLastVehicle Year, Make/ModelVehicle TypeCarVanSUVTruckDistance Willing to Drive Under 10 milesUp to 25 milesOver 25 milesRide Types (check all that apply)MedicalShoppingHair Appts/ErrandsNextI have a valid state license and registrationYesNoI am physically and mentally capable of driving my vehicle safely. If there is any question on my driving ability, I will inform the office and not provide rides. If I am on medical leave, I may be asked to provide a release from my physician stating I can drive again.YesNoI have a good driving record.YesNoI will notify Eastside Senior Services of any insurance, vehicle, or license changes.YesNoI will protect the riders’ right to confidentiality and be nonjudgmental. If I have any concerns about a rider or situation, I will contact the office immediately.YesNoTo protect my personal safety and the safety of the rider, I will NOT help the rider up should the rider fall. Instead I will call 911 for assistance.YesNoI will contact the office if an accident or incident occurs.YesNoI will contact the office should I feel the client’s needs are beyond the ability of the program or if I feel uncomfortable in any way.YesNoIf a handicap permit is issued to me, I will only use it during the time I am transporting riders. I will return the permit to the office when I am no longer able to drive.YesNoPreviousNextMy insurance is current and covers the Min Auto Liability Insurance Limits for Wisconsin: Property Damage $10,000; Bodily Injury Liability $25,000 per person/$50,000 per occurrence.YesNoI understand that Eastside Senior Services has Excess Automobile Liability Insurance that applies only after my insurance is exhausted. This insurance covers bodily injury or property damage claims while performing my volunteer assignment. This coverage does not apply to my vehicle damage.YesNoPreviousNextFunctional doors/handleYesNoWindshield wipers in good condition/washer fluid filledYesNoAll lights working (Headlights, tail lights, turn signals)YesNo Safety: Seatbelts work and Air Bags are operationalYesNo Tires with good tread and proper inflationYesNo Heater/defroster/air conditioning workingYesNo Side mirrors/rear view mirrors presentYesNoBrakes in good conditionYesNoIce scraper/snow brush presentYesNoVehicle is in safe mechanical conditionYesNoSignature Clear Signature Please use your mouse to signEmail *NameSubmit
