Please enable JavaScript in your browser to complete this form.
Volunteer Driver Agreement
Please enable JavaScript in your browser to complete this form.
-
Step
1
of 4
Name
*
First
Last
Vehicle Year, Make/Model
Vehicle Type
Car
Van
SUV
Truck
Distance Willing to Drive
Under 10 miles
Up to 25 miles
Over 25 miles
Ride Types (check all that apply)
Medical
Shopping
Hair Appts/Errands
Next
I have a valid state license and registration
Yes
No
I 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.
Yes
No
I have a good driving record.
Yes
No
I will notify Eastside Senior Services of any insurance, vehicle, or license changes.
Yes
No
I 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.
Yes
No
To 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.
Yes
No
I will contact the office if an accident or incident occurs.
Yes
No
I 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.
Yes
No
If 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.
Yes
No
Next
My 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.
Yes
No
I 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.
Yes
No
Next
Functional doors/handle
Yes
No
Windshield wipers in good condition/washer fluid filled
Yes
No
All lights working (Headlights, tail lights, turn signals)
Yes
No
Safety: Seatbelts work and Air Bags are operational
Yes
No
Tires with good tread and proper inflation
Yes
No
Heater/defroster/air conditioning working
Yes
No
Side mirrors/rear view mirrors present
Yes
No
Brakes in good condition
Yes
No
Ice scraper/snow brush present
Yes
No
Vehicle is in safe mechanical condition
Yes
No
Signature
Clear Signature
Please use your mouse to sign
Email
*
Name
Submit